UNIVERSITY  OF  CALIFORNIA 

COLLEGE  OF  MEDWE 

'  'f^^upy 

•     .'III      2 1971 

'WINE.  CALIFORNIA  9266* 


PHYSICAL  DIAGNOSIS 


PHYSICAL   DIAGNOSIS 


WITH  CASE  EXAMPLES  OF   THE 
INDUCTIVE  METHOD 


BY 

J.  AND 


HOWARD   S.  ANDERS,  A.M.,  M.D. 

PROFESSOR   OF    PHYSICAL    DIAGNOSIS,    MEDICO-CHIRURGICAL   COLLEGE,  PHILADF.LPHIA 
PHYSICIAN  TO  THE   PHILADELPHIA   GENERAL   HOSPITAL,  TUBERCULOSIS   DEPART- 
MENT ;    LATE   PRESIDENT   OF    THE    PENNSYLVANIA   SOCIETY    FOR    THE    PRE- 
VENTION   OF   TUBERCULOSIS  ;    MEMBER   AMERICAN   MEDICAL    ASSOCIA- 
TION,    AMERICAN     CLIMATOLOGICAL     ASSOCIATION,     AMERICAN 
ASSOCIATION   FOR   THE   ADVANCEMENT   OF   SCIENCE,    ETC. 


WITH  EIGHTY-EIGHT   ILLUSTRATIONS   IN  THE   TEXT 
AND    THIRTY-TWO    PLATES 


NEW  YORK  AND   LONDON 
D.    APPLETON    AND    COMPANY 

1907 


COPYRIGHT,  1907,  BY 
D.   APPLETON  AND  COMPANY 


PRINTED   AT   THE   APPLETON   PRESS 
NEW   YORK,    U.    S.    A. 


PREFACE 


IN  these  days  of  extensive,,  almost  entangling,  and  yet  generally 
exact  laboratory  training  in  the  methods  and  processes  of  diagnosis, 
there  is  a  tendency  among  medical  students  to  slight  and  become 
superficial  in  the  responsibility  and  cultivation  of  careful  and  minute 

V 

clinical  observation:  students  are  more  apt  to  scrutinize  the  chemical 

'"•• 
'_  and  microscopic  aspects  of  a  patient's  secretions  and  excretions  than  to 

perceive  and  analyze  his  physical  signs  and  objective  symptoms.     With 

a  clear  appreciation  of  the  accuracy  and  utility  of  laboratory  results  in 

their  wonderful  details  and  penetrating  ramifications,  it  behooves  us, 

Q 'nevertheless,  to  enlarge  upon  and  emphasize,  in  the  following  pages, 

\  the  physical  methods  of  observation  of  the  individual's  bodily  organs 

and  their  functions. 

JUc 

In   my   teaching   experience    it   has    appeared   that   the   average 

medical  student  tends  to  neglect  or  misapprehend  the  intrinsic  im- 
portance of  two  things,  namely:  technic  and  reason.  He  is  inclined 
to  exhibit  a  superficial  and  hasty  zeal  and  endeavor  to  get  at  the 
physical  signs  somehow,  but  without  methodic  and  patient  proce- 
dure and  practise;  and  his  mental  drift  is  toward  jumping  at 
conclusions  from  insufficient  data  and  inefficient  correlation. 

It  is  the  double-barreled  purpose  of  this  book,  its  dual  raison 
d'etre,  to  counteract,  as  far  as  text-book  influence  may  (of  course, 
less  potent  than  the  personal  power  of  the  teacher),  this  deficiency 
^  and  tendency  in  the  student  body  of  our  medical  colleges. 

First,  insistence  and  emphasis  is  to  be  placed  upon  technical 
practise  and  precision;  upon  those  principles  of  action  and  methods 
of  procedure,  concentrated  and  painstaking  attention  to  which  will 
*"  prevent  meager  and  confused  results  in  the  interpretation  of  the 
signs  thus  elicited. 


vi  PREFACE 

Secondly,  the  inculcation  of  the  inductive  habit  of  thinking:  the 
analysis  of  observed  facts;  the  perception  of  their  similarity  <>f 
meaning;  and  thus  the  avoidance  of  an  inconsequential,  fallacious 
empiricism.  We  need  in  clinical  work  more  of  the  line  of  diagnostic 
thinking  exemplified  by  Dr.  (Sir)  Arthur  Conan  Doyle's  immortal 
consulting  detective,  namely,  the  "  synthetic  induction "  habit ;  in- 
deed, it  is  the  author's  custom  to  recommend  to  medical  students 
the  careful  reading  of  the  "  Adventures  and  Memoirs  of  Sherlock 
Holmes."  It  is  in  the  province  of  the  physician  to  discover  the 
evidences  (signs)  of  disease  as  it  was  his  to  detect  those  of  crime; 
to  deduce  the  meaning  and  identity  of  the  signs  (the  logic  of 
synthesis) ;  then  to  collect  and  correlate  these  separate  deductions 
and  to  perceive  their  similarity  in  harmony  with  a  single  conclu- 
sion inferred  from  them  (the  logic  of  induction). 

It  will  be  noticed,  however,  that  the  application  of  the  inductive 
method  is  limited  to  the  sections  on  the  special  physical  diagnosis 
of  diseases  of  the  lungs  and  heart;  to  the  citation  and  analysis  of 
certain  individual  cases  illustrating  the  method;  it  would,  obviously, 
be  irrelevant  and  irrational  to  force  the  inductive  treatment  of  the 
subject  throughout  the  work,  particularly  at  the  beginning,  where 
the  elemental  facts  and  principles  and  the  description  and  details 
of  technic  must  first  be  apprehended  in  order  to  make  the  method 
productive. 

It  is  the  spirit,  the  trend  of  the  inductive  method  which  is 
adopted  here.  The  purpose  is  not  to  be  cyclopedic  in  the  mere 
enumeration  of  physical  signs  to  burden  the  memory:  the  technical, 
logical,  and  practical  are  more  worthy  of  emphasis  and  develop- 
ment. It  is  vitally  important  that  the  student,  in  the  practise  of 
a  careful  technic,  gains  assurance  of  observation  and  intelligence 
of  apperception;  and  that  he  learns  to  think  logically  upon  what 
he  thus  finds. 

It  is  hoped  that  this  book  may  accord,  in  some  measure,  with 
the  ideals,  standards,  and  rapidly  rising  requirements  of  modern 
training  in  our  medical  schools  of  all  sizes,  rank  of  attainment, 
prestige,  and  affiliation.  We  believe  that,  at  the  present  time,  the 


PEEFACE  vii 

majority  of  students  graduated  from  our  medical  colleges  fall  far 
short  of  an  adequate  knowledge  of  the  facts,  principles,  and  clinical 
importance  of  physical  diagnosis,  and  of  practical  training  in  the 
technic  of  the  methods  of  physical  examination. 

Furthermore,  in  view  of  the  increasing  number — already  consid- 
erable— of  medical  examiners  for  life-insurance  companies,  and  of 
physical  directors  for  college,  club,  and  Y.  M.  C.  A.  gymnasiums, 
what  has  just  been  indicated  in  the  previous  paragraph  calls  for 
serious,  energetic,  and  enthusiastic  reflection  and  regeneration.  Be- 
sides, it  may  not  be  questioned  that  a  more  thorough  teaching  of 
physical  diagnosis,  in  its  essentials  at  least,  should  be  given  in  our 
dental  college  curricula;  dental  students  should  be  required  to  learn 
especially  those  physical  signs  of  the  heart  which  so  constantly  sus- 
tain vital  relations  to  the  precautions,  complications,  and  progress 
of  anesthesia. 

Other  works  and  the  latest  literature  bearing  upon  the  subject 
have  been  drawn  upon  for  many  of  the  long-established  and  lately 
demonstrated  facts  tested  and  proven  by  competent  experience. 

As  to  the  illustrations,  most  of  which  were  borrowed  because  of 
their  suitability  to  the  text,  the  author  wishes  to  express,  however 
feebly,  his  especial  appreciation  and  admiration  of  those  loaned  by 
Dr.  Glentworth  E.  Butler  with  the  kindest  courtesy  possible. 

Finally,  to  Dr.  Pfahler  I  am  highly  indebted  for  his  valuable 
chapter  on  Eontgenography,  and  for  the  use  of  his  very  fine  and 
rare  and  complete  Eontgenograms.  It  is  a  pleasure  to  commend 
his  technical  ingenuity  and  skill  not  only,  but  his  penetrating  and 
judicious  clinical  interpretations  as  well. 

H.  S.  A. 

1836  WALLACE  STREET,  PHILADELPHIA. 


CONTENTS 


INTRODUCTION 


DEFINITION      .        .        . 
STANDPOINT  AND  IMPORTANCE 


PART  I 

THE  CHEST   (THORAX) 


PHYSICAL  SIGNS 

PHYSICAL  DIAGNOSIS  AS  A  SCIENCE 

RELATIONS  OF  PHYSICAL  DIAGNOSIS 

QUALIFICATIONS  FOR  THE  STUDY  OF  PHYSICAL  DIAGNOSIS  .... 

THE  BENEFITS 


SECTION  I 

METHODS  AND  TECHNIC :    PHYSICAL  SIGNS  AND 
DIAGNOSIS  IN  GENERAL 

CHAPTER   I 

TOPOGRAPHIC  AND  RELATIONAL  ANATOMY  OF  THE  CHEST 

ANATOMIC  LANDMARKS  OF  THE  CHEST 

TOPOGRAPHIC  REGIONS  OF  THE  CHEST  AND  RELATIONAL  ANATOMY     .        .  17 

ARBITRARY  LINES  AS  LANDMARKS 17 

REGIONS: 

ANTERIOR  ASPECT 1° 

LATERAL  ASPECT 22 

POSTERIOR  ASPECT 22 

RELATIONAL  ANATOMY  (LANDMARKS  OF  THE  LUNGS) 24 

RELATIONAL  ANATOMY  OF  THE  PLEURAL  SACS  (PLEURAE)    ....  26 

ADDITIONAL  ANATOMIC  LANDMARKS 27 

CHAPTER  II 
INSPECTION 

THE  NORMAL  THORAX 

MENSURATION 


x  CONTENTS 

THE  PATHOLOGIC  THORAX  PAGE 

(1)  SIZE 41 

(2)  SHAPE 42 

(3)  SYMMETRY 47 

(4)  RESPIRATORY  MOVEMENTS 51 

(5)  LITTEN'S  SIGN 58 

(6)  ABNORMAL  RATE  AND  RHYTHM  OF  RESPIRATION:  DYSPNEA      .        .  59 

CHAPTER   III 
PALPATION 

GENERAL  METHOD  OF  PALPATION 63 

PALPATION  OF  CERTAIN  INSPECTED  SIGNS 64 

THORACIC  VIBRATIONS: 

VOCAL  FREMITUS 65 

NORMAL 65 

PATHOLOGIC 67 

CHAPTER   IV 
•     PERCUSSION 

METHODS  OF  PERCUSSION 74 

THORACIC  PERCUSSION  SOUNDS 85 

ATTRIBUTES  OF  PERCUSSION  SOUNDS 86 

TOPOGRAPHIC  PERCUSSION 103 

CHAPTER   V 

PERCUSSION  (Concluded) 

THORACIC  PERCUSSION  SOUNDS  (Concluded) 108 

ABNORMAL    PERCUSSION    SOUNDS    DUE    TO  DISEASES  OF  THE  LUNGS 

AND  PLEURAE 108 

A.  DULNESS:  IMPAIRED  OR  DEADENED  RESONANCE      ....  109 

B.  EXAGGERATED     OR   ABNORMALLY    CLEAR    RESONANCE;     HYPI:R- 

RESONANCE;  VESICULOTYMPANITIC  RESONANCE       .        .        .  116 

C.  TYMPANITIC  SOUND  AND  ITS  VARIATIONS 118 

D.  AMPHORIC  OR  METALLIC  RESONANCE 125 

E.  CRACKED-POT  SOUND  (BRUIT  DE  POT  FELE)     .        .        .        .        .  127 

F.  THE  LUNG  REFLEX 129 

ALTERED  CONDITION  OF  LUNG   BOUNDARIES;  POSITION  AND  MOBILITY 

AS  DETERMINED  BY  PERCUSSION 130 

CHAPTER   VI 
AUSCULTATION 

METHODS 133 

AUSCULTATORY  PHENOMENA        .       .       .               144 

THE  SOUNDS  OF  NORMAL  RESPIRATION 145 

SOUNDS  OF  ABNORMAL  RESPIRATORY  CONDITIONS 152 

(A)  PATHOLOGIC  MODIFICATIONS  OF  VESICULAR  BREATHING       .       .  153 


CONTENTS  xi 

CHAPTER  VII 
AUSCULTATION  (Concluded) 

PAGE 

AUSCULTATORY  PHENOMENA  (Concluded) 168 

SOUNDS  OF  ABNORMAL  RESPIRATORY  CONDITIONS  (Concluded)        .        .  168 

(B)  ADVENTITIOUS  SOUNDS 168 

(C)  THE  VOCAL  RESONANCE .        .188 

(D)  AUSCULTATION  OF  THE  COUGH:  TUSSIVE  RESONANCE    .        .        .  194 
EXPLORATORY  PUNCTURE  OF  THE  PLEURA  (THORACENTESIS)      .        .        .  195 
COMBINATION  OF  THE  PHYSICAL  SIGXS:  THEIR  ASSOCIATED  SIGNIFICANCE   .  196 


SECTION  II 

SPECIAL    PHYSICAL    DIAGNOSIS    OF    SOME    DISEASES    OF    THE 
RESPIRATORY  TRACT,   INDUCTIVELY  CONSIDERED 

CHAPTER  VIII 
HYPOTHETICAL  AND  RECORDED  CASES  199 


SECTION   III 
THE  HEART  AND  PERICARDIUM 

CHAPTER  IX 
INSPECTION 

TOPOGRAPHIC  AND  RELATIONAL  ANATOMY  OF  THE  HEART  AND  THE  VALVES     214 
METHOD  OF  INSPECTION  OF  THE  HEART 221 

CHAPTER  X 

PALPATION 

SHAPE  OF  THE  PRECORDIUM 236 

ABNORMAL  PULSATIONS 237 

THE  APEX-BEAT 238 

ADVENTITIOUS  PALPABLE  SIGNS 241 

CHAPTER   XI 
PERCUSSION 

PERCUSSION  OF  THE  NORMAL  HEART        ....  ...     245 

ABNORMAL  AREAS  OF  CARDIAC  DULNESS  253 


xii  CONTENTS 

CHAPTER  XII 

AUSCULTATION 

PACK 

METHOD  OF  EXAMINATION 259 

THE  NORMAL  HEART: 

NORMAL  HEART  SOUNDS 260 

VALVE  AREAS 264 

PHYSIOLOGIC  VARIATIONS  OF  THE  HEART  SOUNDS 267 

PATHOLOGIC  MODIFICATIONS  OF  THE  HEART  SOUNDS 269 

CHAPTER   XIII 

AUSCULTATION  (Concluded) 

ADVENTITIOUS  SOUNDS  OR  CARDIAC  MURMURS 282 

(A)  CLASSIFICATIONS  OF  MURMURS 282 

(fi)  MODE  OF  PRODUCTION  OF  MURMURS 283 

(C)  MULTIPLE  OR  COMBINED  MURMURS 299 

(D)  FUNCTIONAL  OR  ACCIDENTAL  MURMURS 303 

EXOCARDIAL  SOUNDS 308 

CHAPTER   XIV 

EXAMINATION  OF  THE  BLOOD-VESSELS 

THE  ARTERIES        .        .                       . 313 

INSPECTION  .        .        .        .        '. 313 

PALPATION 315 

THE  PULSE 316 

AUSCULTATION 337 

THE  CAPILLARIES 339 

THE  VEINS 340 

INSPECTION  .               340 

PALPATION   .               344 

AUSCULTATION  346 


SECTION   IV 
SPECIAL  PHYSICAL  DIAGNOSIS 

CHAPTER  XV 
DISEASES  OF  THE  HEART.  INDUCTIVELY  CONSIDERED    .  348 


CONTENTS  xiii 

PART   II 
THE  ABDOMEN  AND  ITS  PRINCIPAL  ORGANS 


SECTION  V 
GENERAL   EXAMINATION  OF  THE  ABDOMEN 

CHAPTER  XVI 

TOPOGRAPHIC  ANATOMY,  REGIONS,  AND  METHODS  OF  ABDOMINAL 
EXAMINATION 

PAGE 

ANATOMIC  ZONES,  REGIONS,  AND  LANDMARKS 363 

METHODS  OF  ABDOMINAL  EXAMINATION 366 

GENERAL  INSPECTION 366 

PALPATION ' 370 

PERCUSSION 378 

AUSCULTATION 379 

SECTION   VI 
THE  PRINCIPAL   SPECIAL   ORGANS   OF   THE  ABDOMEN 

CHAPTER  XVII 
THE  STOMACH  AND  INTESTINES 

TOPOGRAPHIC  ANATOMY  OF  THE  STOMACH       .        .        .        .        .        .        .  381 

PHYSICAL  EXAMINATION  OF  THE  STOMACH: 

INSPECTION 382 

PALPATION 383 

PERCUSSION 384 

AUSCULTATION 387 

TOPOGRAPHIC  ANATOMY  OF  THE  INTESTINES 388 

PHYSICAL  EXAMINATION  OF  THE  INTESTINES: 

INSPECTION 388 

PALPATION 388 

PERCUSSION 389 

AUSCULTATION 390 

CHAPTER  XVIII 

THE  LIVER,  SPLEEN,  AND  KIDNEYS 

TOPOGRAPHIC  ANATOMY  OF  THE  LIVER 391 

EXAMINATION  OF  THE  LIVER: 

INSPECTION ...  392 

PALPATION 393 

PERCUSSION 397 

AUSCULTATION  ....  400 


xiv  CONTENTS 

PAGE 

TOPOGRAPHIC  ANATOMY  OF  THE  SPLEEN 401 

EXAMINATION  OF  THE  SPLEEN: 

INSPECTION 402 

PALPATION 402 

PERCUSSION 405 

AUSCULTATION 407 

TOPOGRAPHIC  ANATOMY  OF  THE  KIDNEYS 407 

EXAMINATION  OF  THE  KIDNEYS 408 

INSPECTION 408 

PALPATION 409 

PERCUSSION 410 


PART  III 
THE  RONTGEN  RAY  IN  MEDICAL  DIAGNOSIS 


CHAPTER  XIX 
THE  RONTGEN  RAY  IN  MEDICAL  DIAGNOSIS 

THE  RELATIVE  VALUE  OF  RONTGENOSCOPY  AND  RONTGENOGRAPHY         .  417 

GENERAL  TECHNIC  OF  RONTGENOGRAPHY  OF  THE  CHEST     ....  418 

TECHNIC  OF  RONTGENOGRAPHY  IN  PATHOLOGIC  CONDITIONS  OF  THE  CHEST  421 

THE  LUNGS 421 

THE  PLEURA 424 

THE  HEART 426 

RONTGEN  EXAMINATION  OF  THE  GASTROINTESTINAL  TRACT      .        .        .  427 

THE  STOMACH 427 

THE  INTESTINES 427 

THE  LIVER " 428 

THE  SPLEEN        .  428 

THE  KIDNEYS     .        .  428 


PART   IV 

RONTGENOGRAMS Following     430 

INDEX  431 


LIST   OF  PLATES 


PLATE  PAGE 

I.     Anterior  Aspect.     Shows  the  Normal  Position  and  Relations  of 
the  Lungs    and   Heart   to  each   other   and  to  the  Bony 

Thorax 13 

II.     Anterior  Aspect.     Shows  the  Cardiac  Relations  with  the  Lungs 

Removed 14 

III.  Posterior  Aspect.     Landmark  Relations  of  the  Lungs  Viewed 

from  the  Back 16 

IV.  Lateral  Aspect  (Right).     Topographic  Relations  of  Right  Lung 

and  Liver  in  the  Inferior  Axillary  Region      ....  18 
V.     Topographic  Relations  (Left  Lateral  Aspect)  of  the  Left  Lung 

and  Spleen,  Inferior  Axillary  Region 20 

VI.     Bony  Landmarks  of  the  Anterior  Surface  of  the  Chest         .        .  22 

VII.     Landmarks  and  Lines  of  the  Lateral  Surface  of  the  Chest          .  24 

VIII.     Landmarks  and  Lines  of  the  Posterior  Surface  of  the  Chest        .  26 
IX.     Abdomen  Divided  into  Sextants  for  the  Localization  of  Physical 

Signs 366 

X.     Surface  Relations  of  the  Liver 392 

XI.     Surface  Projection  of  the  Right  Kidney:  Anterior  Relations  of 

Spleen 406 


RONTGENOGRAMS 
(GROUPED,  FOLLOWING  PAGE  430) 

XII.     A.  Normal  Thorax  of  a  Young  Man. — B.  Incipient  Tuberculosis. 

XIII.  A.  Infiltration  of  both  Apices. — B.  Fibrous  Bands  at  the  Apices  of 

Both  Lungs. 

XIV.  A.  General  Infiltration  of  Both  Lungs. — B.  General  Infiltration  with 

Area  of  Consolidation. 
XV.     A.  Large  Area  of  Complete  Consolidation  Lying  to  the  Left  of  the 

Heart. — B.  A  Nine-year-old  Child.     Posterior  View. 
XVI.     A .  Consolidation  of  the  Left  Lung. — B.  General  Infiltration  of  Both 

Lungs. 
XVII.     A.  Consolidation  of  the  Right  Apex,  etc. — B.  Complete  Consolidation 

with  Abscess  Formation. 
XVIII.     A.  Abscess  of  the  Left  Lung,  etc. — B.  Gangrene  of  the  Lung. 


XVI 


LIST    OF    1'LATKS 


I'l.ATK 

XIX.     A.  Same  Case  as  Plate  XVIII,  B,  After  Operation.— B.  General  Small 

and  Probably  Early  Infiltration. 

XX.     A.  Pleural  Effusion. — B.  Left-sided  Pneumothorax. 
XXI.     A.    Hemothorax   on   the   Left   Side   of   the  Chest. — B.   Subphrenic 

Abscess  of  the  Right  Side. 

XXII.  A.  A  Nine-year-old  Child.  Anterior  View. — B.  Marked  Hypertrophy 
and  Dilation  of  the  Left  Ventricle. 

XXIII.  A .  Hypertrophy  of  the  Right  Ventricle  and  Left  Auricle. — B.  Marked 

Cardiac  Dilation. 

XXIV.  Dextrocardia  due  to  Tuberculosis. 

XXV.  A.  Dextrocardia  Tuberculous  Deposits  in  the  Left  Apex. — B.  Shows 
(1)  The  Left  Side  of  the  Diaphragm  Four  Inches  Higher  than  tin- 
Right;  (2)  The  Heart  Displaced  to  the  Right,  etc. 

XXVI.     A.  Aneurism  of  the  Arch  of  the  Aorta. — B.  Aneurism  of  the  Descend- 
ing Aorta. 

XXVII.     Tortuosity  of  the  Arch  of  the  Aorta. 
XXVIII.     Gastroptosis. 
XXIX.     Gastroptosis. 
XXX.     Case  of  Gastroptosis. 
XXXI.     Transverse  Colon,  etc. 
XXXII.     Cecum  and  Ascending  Colon,  etc. 


LIST   OF   ILLUSTRATIONS   IN  TEXT 


FIG.  PAGE 

1.  Showing  the  Topographic  Areas  of  the  Thorax  Anteriorly     ...  19 

2.  Showing  the  Topographic  Areas  of  the  Trunk  Posteriorly     ...  23 

3.  Showing  the  Lobes  of  the  Lung  and  the  Lower  Limit  of  the  Pleura  on 

the  Right  Side  of  the  Chest 25 

4.  Showing  the  Lobes  of  the  Lungs  and  the  Lower  Limit  of  the  Pleura 

Posteriorly 26 

5.  Diagram    Illustrating   the   Mechanism    of   the    Diaphragmatic    Phe- 

nomenon            32 

6.  Thoracometer 37 

7.  Hall's  Chest  Pantograph 38 

8.  Chest  Pantograms 39 

9.  The  Normal  Thorax 42 

10.  Anterior  and  Posterior  Aspects  of  the  Phthisinoid  Chest        ...  43 

11.  The  Flat  Phthisical  Chest 43 

12.  Emphysematous  Chest 44 

13.  Simple  Rachitic  Chest 45 

1J      Transverse  Section  of  a  Rachitic  Chest 46 

15      Funnel  Breast 47 

16.  Unilateral  Retraction  of  Chest .        .48 

17.  Unilateral  Enlargement  of  Chest 49 

18.  Sansom's  Pleximeter 76 

19.  Wintrich's  Percussion  Hammer 76 

20.  Diagram  showing  the  Rationale  and  Utility  of  Varying  the  Force  of 

the  Percussion  Stroke 80 

21.  Diagram  showing  the  Theory  of  Au?cultatory  Percussion      ...  83 

22.  Diagram  showing  the  Lines  to  which  Auscultatory  Percussion  should 

be  carried 83 

23.  Diagrammatic  Sketch  of  the  Relations  of  the  Elements  of  Tone         .  96 

24.  Showing  the  Relative  Resonance  of  Various  Portions  of  the  Anterior 

Surface  of  the  Thorax 105 

25.  Showing  the  Variations  of  Lessened  Resonance 112 

26.  Showing  the  Dulness  Due  to  Fluid  in  the  Left  Complementary  (Re- 

flected) Pleura 114 

27.  Showing  Certain  Percussion  and  Auscultatory  Findings     .        .        .118 

28.  Diagram   showing   the  Physical   Conditions  which  cause  Hyperreso- 

nance  and  Tympanitic  or  Amphoric  Percussion  Sounds         .        .  120 

29.  Hawksley's  Single  Stethoscope 135 

30.  Cammann's  Double  Stethoscope  and  Snelling's  Rubber  Bell         .        .  136 

1*  xvii 


xviii  LIST    OF    ILLfSTKATlONS    IN    TEXT 

,..|,;.  PAGE 

31.  Simple  Form  of  Sansom's  Binaural  Stethoscope 137 

32.  Binaural  Stethoscope 137 

33.  Author's  Binaural  Stethoscope  Chest  Piece 138 

34.  Bowles's  Stethoscope 138 

35.  Phonendoscope 140 

36.  Shows  where  Broncho- Vesicular  Breathing  Normally  Exists       .        .  146 

37.  Showing  the  Site  of  Normal  Bronchial  and  Broncho- Vesicular  Breath- 

ing (Posteriorly)     . .147 

38.  Diagrammatic  Representation  of  the  Varieties  of  Vesicular  Breathing  156 

39.  Diagrammatic  Representation  of  Prolonged  Pause          ....  157 

40.  Schematic  Diagram  of  the  Varieties  of  Breathing  and  Vocal  Resonance 

in  Disease 165 

41.  Diagrammatic  Illustration  of  Dry  or  Moist  Rales 171 

42.  The  Anterior  Aspect  of  the  Normal  Heart  and  Great  Vessels       .        .  215 

43.  Position  of  the  Cardiac  Orifices  in  Relation  to  the  Surface  of  the  Chest  219 

44.  Showing  the  Indications  to  be  Obtained  from  the  Position  of  the 

Apex-beat 224 

45.  Showing  the  Exposed  and  Covered  Dulness  of  the  Normal  Heart       .  248 

46.  Showing  the  Principal  Lines  along  which  Percussion  should  be  Con- 

ducted to  Ascertain  the  Area  of  Cardiac  Dulness    ....  251 

47.  Normal  Area  of  Entire  Cardiac  Dulness 253 

48.  Dulness  in  Hypertrophy  of  the  Left  Ventricle 254 

49.  Dulness  in  Hypertrophy  and  Dilation  of  the  Right  Heart     .        .        .  254 

50.  Showing   the   Dulness   due   to   Dilation   and   Hypertrophy   of   both 

Ventricles 255 

51.  Absolute  Dulness  in  case  of  Acute  Pericarditis 256 

52.  Normal  Cardiac  Cycle 261 

53.  Diagrammatic  Representation  of  the  Movements  and  Sounds  of  the 

Heart 263 

54.  Areas  of  the  Cardiac  Murmurs 265 

55.  Showing  the  Position  of  the  Valves  of  the  Heart  and  the  Areas  of  their 

Greatest  Audibility 266 

56.  Diagram   Representing  Two   Variations   from   the   Normal   Cardiac 

Rhythm 278 

57.  A.  Normal   First   and   Second   Sounds. — B.  Reduplicated   and   Ac- 

centuated Second  Sound 280 

58.  Showing  Precordial  Areas 286 

59.  Diagram  showing  the  three  Chronologic  Types  of  Murmurs  .        .        .  289 

60.  Mitral  Systolic  Murmur 291 

61.  Mitral  Presystolic  Murmur 292 

62.  Aortic  Systolic  Murmur        .                               293 

63.  Aortic  Diastolic  Murmur 294 

64.  Tricuspid  Systolic  Murmur 294 

65.  Combined  Murmurs  of  Aortic  Incompetence  and  Stenosis  and  Mitral 

Incompetency 302 

66.  Showing  the  Relative  Frequency  of  Anemic  Murmurs    ....  303 

67.  Usual  Location  of  Pericardial  Friction  Sound  and  Fremitus       .        .  309 

68.  Stanton's  Sphygmomanometer 326 

69.  Janeway's  Sphygmomanometer 328 


LIST    OF    ILLUSTKAT10NS    IN    TEXT  xix 

FIG.  PAGE 

70.  Tracing  from  the  Pulse  of  a  Normal  Man 331 

71.  Sphygmograms,  Diagrammatic  and  Actual 334 

72.  Sphygmograms,  Actual 335 

73.  Diagram  of  the  Right  External  and  Internal  Jugulars   ....  342 

74.  Diagram  showing  the  Presystolic  and  Systolic  Jugular  Pulse        .        .  344 

75.  Showing  nine  Topographic  Areas  of  Abdomen 364 

76.  Viscera  of  the  Thorax  and  Abdomen  as  seen  from  Behind    .        .        .  365 

77.  General  Enlargement  of  the  Abdomen  from  Abdominal  Dropsy  .        .  368 

78.  Showing  the  Central  Tympanicity  and  Lateral  Dulness  of  an  Abdomen 

Containing  Free  Fluid 379 

79.  Showing  Central   Dulness   and   Lateral  Tympanicity  of   Abdominal 

Cystic  or  Solid  Tumors 379 

80.  To   Determine   the   Outline   of  the  Stomach   by  Auscultatory  Per- 

cussion       386 

81.  Showing  the  Method  of  Determining  by  Auscultatory  Percussion  that 

a  Tumor  belongs  to  the  Stomach 386 

82.  Showing  the  Points  which  Determine  the  Size  and  Position  of  the 

Normal  Liver 392 

83.  Showing  the  Surface  Topography  of  the  Spleen 401 

84.  Palpation  of  the  Spleen .        .        .403 

85.  Showing  the  Normal  Surface  Relations  of  the  Kidneys  Anteriorly     .  407 

86.  Showing  Surface  Relations  of  Kidneys  Posteriorly          ....  408 

87.  Tumor  of  Spleen 412 

88.  Tumor  of  the  Left  Kidney 412 


INTRODUCTION 


Definition. — Practically,  physical  diagnosis  is  the  art  of  detect- 
ing and  discriminating  diseases  of  the  chest  and  abdomen  by  the 
aid  of  signs  denoting  the  abnormal  physical  conditions  of  the  organs 
or  structures  under  examination. 

Broadly  speaking,  it  is  the  objective  investigation  of  the  whole 
body  by  the  use  of  the  physician's  special  senses,  especially  of  sight, 
of  touch,  and  of  hearing,  with  the  appropriate  aid  of  instruments  of 
precision;  so  that  the  perceived  and  demonstrable  results  of  the 
physical  examination,  in  the  physical  signs  elicited,  may,  severally 
or  conjointly,  be  said  to  be  visible,  palpable,  and  audible.  In  the 
scientific  development  of  medical  practise,  however,  the  methods  of 
physical  diagnosis  are  recognized  as  most  applicable  to  the  deter- 
mination of  the  anatomic  and  physiologic  deviations  caused  by 
affections  of  the  thoracic  and  abdominal  viscera:  thus,  of  the  chest, 
the  heart  and  lungs  are  examined  and  studied ;  of  the  belly,  the  liver, 
spleen,  stomach,  bowels,  and  kidneys.  As,  early  in  the  century  just 
past,  Piorry,  in  France,  expressed  it  in  his  word  "  organography,"  the 
idea  of  physical  diagnosis  is  embraced  fairly  well  in  the  determina- 
tion of  the  actual  and  relative  position,  material  condition,  and  sensi- 
ble functional  action  of  the  organs  contained  within  the  body. 

Standpoint  and  Importance. — To  the  superficial  comprehensiveness 
of  the  "physiognomy  of  disease"  (Gairdner)  physical  diagnosis  adds 
penetration  and  precision  of  method,  and  rational  reliability  of  evi- 
dence; the  value  of  the  objective  symptoms  of  the  former  being  con- 
trolled and  tested,  augmented  or  invalidated,  by  the  physical  signs 
of  the  latter.  Thus,  while  such  external  phenomena  as  refer  to  the 
general  appearance  of  the  patient  may  indicate  as  a  guide-post  the  in- 
ternal organ  or  organs  in  which  disease  is  to  be  looked  for,  it  is  only 
as  the  methods  of  physical  examination  are  carefully  applied  that  we 
really  learn  the  presence,  character,  extent,  and  stage  of  an  organic 
pulmonary  or  cardiac  affection.  For  instance,  we  may  note  the 
stature,  build,  posture,  complexion,  and  facial  expression,  apparent 

3 


4  PHYSICAL   DIAGNOSIS 

age  as  compared  with  the  real  age,  finger-ends,  dropsy,  dyspnea,  tem- 
perature, cough,  etc.,  pointing  to  thoracic  disease,  in  the  line  of 
physiognomic  diagnosis.  When  the  intimate  association  of  the 
respiratory  and  circulatory  functions  is  realized,  however,  obviously 
it  is  impossible  to  define  with  any  precision  whether  the  heart  or  a 
lung  is  the  seat  of  disease,  what  that  disease  is,  what  it  involves,  and 
whether  or  not  both  systems  are  affected  independently  or  sequentially, 
unless  the  more  exact  results  of  systematic  physical  exploration  are 
sought  for  and  explained. 

The  importance,  then,  of  physical  diagnosis,  in  diseases  of  the 
chest  especially,  exists  primarily  and  essentially  in  the  fact  that  it 
puts  forth  physical  evidence  of  morbid  changes  and  pathologic  proc- 
esses which  can  be  learned  in  no  other  way  than  by  the  trained 
eye,  ear,  and  hand  of  the  responsible  physician;  evidence  gotten  in- 
dependently of  the  sometimes  misleading  and  malingered  statements 
of  the  patient's  medical  history  or  symptoms;  and  secondarily  and 
indirectly  because  it  not  only  serves  as  a  check  or  control  over  the 
significance  of  the  complexus  of  mere  symptoms  of  thoracic  affec- 
tions, but  because  it  contributes  such  positive  and  accurate  evidence 
as  to  enhance  the  value  of  a  rational  symptomatology  and  give  com- 
pleteness to  the  general  medical  diagnosis:  our  whole  clinical  con- 
ception of  a  given  case  is  rendered  clearer,  deeper,  and  broader  in  the 
related  facts  of  its  etiology,  pathologic  anatomy,  and  semeiology;  and 
by  so  much  prepares  for  and  sustains  a  wiser  prognosis  and  safer  and 
more  successful  management. 

Physical  Signs. — These  have  been  referred  to  following  the  defini- 
tion of  physical  diagnosis,  and  it  is  simply  purposed  here  to  describe 
more  definitely  their  general  character  and  meaning.  It  should  be 
borne  in  mind  that  while  purely  objective  manifestations,  physical 
signs  are  not  to  be  confused  with  objective  symptoms,  so-called ;  par- 
ticularly as  the  latter  are  not  infrequently  spoken  of  as  "  signs  "  of 
disease.  A  physical  sign  is  always  objective;  but  an  objective  phe- 
nomenon is  not  necessarily  or  always  a  physical  sign,  for  it  may  be 
only  an  objective  symptom.  To  illustrate :  rapidity  of  respiration  and 
a  one-sided  bulging  of  the  chest  are  objectively  perceived;  but  the 
former  is  a  symptom  discovered  by  the  general  observation,  while 
the  latter  is  a  physical  sign  observed  by  the  special,  comparative, 
and  critical  method  of  inspection.  Again,  breathlessness  (dyspnea), 
a  bluish  pallor  of  the  lips  and  cheeks  (cyanosis),  are  objective  symp- 
toms or  signs;  while  an  irregular,  turbulent  throbbing  over  the  heart 
and  an  abnormal  position  of  the  apex-beat  (palpable)  and  weak, 


INTRODUCTION  5 

arhythmic  sounds  (audible)  are  physical  signs  elicited  by  the  special 
methods  of  palpation  and  auscultation.  It  should  be  noted,  too,  that 
subjective  symptoms,  or  those  felt  only  by  the  patient,  as  pain,  ver- 
tigo, are  not  all  exclusively  so;  for  example,  coughing  and  shortness 
of  breath  are  both  subjective-objective  symptoms,  recognized  by  the 
physician  as  well  as  known  to  the  patient. 

It  is  literally  true,  then,  that  physical  signs  are  special  signs, 
(1)  because  recognized  objectively  by  the  three  special  senses  of  the 
physician — vision,  feeling,  and  hearing;  (2)  because  they  are  the 
result  of  the  application  of  special  methods  of  physical  examination. 
They  are  physical  signs  because  they  represent  changes  in  the  physical 
properties  of  organs  consequent  upon  certain  anatomic  conditions 
and  changes.  They  are  thus  present  in  health  as  well  as  in  disease; 
and,  logically,  they  must  be  known  in  states  of  health  before  they 
can  be  the  means  of  aiding  us  in  distinguishing  diseased  conditions 
from  normal  conditions;  and  further,  it  must  be  known  what  struc- 
tural changes  they  evidence  in  the  various  affections,  in  order  that 
these  may  be  differentiated.  "  Symptoms  guide  us,  generally,  by 
physiological  inference;  physical  signs,  by  anatomical  necessity" 
(Hartshorne).  Our  knowledge  of  the  significance  and  value  of 
physical  signs  is,  of  course,  the  outcome  of  close,  extended,  and 
multitudinous  observations,  confirmed  by  examinations  of  the  morbid 
changes  discovered  post  mortem',  and  by  clinical  pathology  (patho- 
logic physiology). 

Physical  Diagnosis  as  a  Science. — Jevons  says  that  "  a  science 
teaches  us  to  know,  and  an  art  to  do."  Not  only  has  physical  diag- 
nosis gradually  acquired  for  itself  this  positive,  precise,  and  practical 
importance  of  a  special  art,  but  it  is  also,  if  not  an  exact  science,  at 
least  largely  and  signally  scientific.  Ophthalmology  has  been  called 
the  most  mathematically  accurate  of  the  specialties  of  medical  prac- 
tise; physical  diagnosis,  the  mathematics  of  internal  medicine;  not 
because  of  any  marked  numerical  certainty,  but  because  of  its  accu- 
racy of  method  and  logical  soundness  and  synthetic  probability  of 
results.  For  science  is  not  only  the  "  observing,  recording,  verifying, 
and  formulating  of  facts  " ;  it  is  also  the  recognition  and  explanation 
of  the  relations  of  facts,  and  the  principles  governing  them.  An  art 
always  presupposes  a  certain  amount  of  science ;  and  it  is  the  province 
of  the  science  of  physical  diagnosis  to  analyze,  collate,  classify,  and 
systematize  into  an  organic  whole  the  known  physical  signs;  to  per- 
ceive their  characteristics,  to  determine  their  causes,  to  interpret  their 
significance. 


6 

The  fact  that  the  art  of  physical  diagnosis  depends  upon  (under 
next  heading)  a  preliminary  knowledge  of  physics,  anatomy,  physiol- 
ogy, pathology — sciences — makes  it  fundamentally  and  truly  scien- 
tific. And  eminently  true  is  it  that  the  method  of  this  practise  is 
hased  upon  the  general  method  of  inductive  logic,  the  logic  of  science, 
involving,  as  it  does,  not  simply  the  collection  of  facts,  but  their 
verification  and  explanation  by  means  of  the  contributory  processes 
of  comparative  observations  and  separate  deductions. 

Relations  of  Physical  Diagnosis. — Physical  diagnosis  is  scientif- 
ically the  eldest,  as  clinical  microscopy  and  clinical  chemistry  are  the 
younger  brothers  in  the  working  out  of  modern  medical  diagnosis; 
worthy  children  of  a  worthy  parent — general  semeiology:  neither, 
alone,  sufficient  without  the  others,  nor  two  combined  without  the 
other,  but  the  precise  and  special  results  of  the  younger  clarifying 
and  controlling,  or  confirming,  and  reciprocally  being  guided  and 
valued  by  the  broad  and  rational  basis  of  the  eldest. 

Physical  diagnosis  is  directly  dependent,  however,  upon  five  (5) 
fundamental  sciences,  the  thorough  study  and  adequate  knowledge 
of  which  are  essential  to  any  accuracy  of  physical  exploration 
and  soundness  of  diagnostic  deduction.  These  are  as  follows: 
(1)  Medical  physics',  (2)  anatomy  (especially  topographic  and  rela- 
tional) ;  (3)  physiology  (including  the  experimental)  ;  (4)  path- 
ology (especially  the  gross  morbid  changes  in  structure) ;  (5) 
logic. 

(1)  The  very  phrase  and  term,  physical  diagnosis  (title,  physi- 
cian), presupposes  a  distinct  cognizance  of  the  phenomena  and  prin- 
ciples of  physics  as  applied  to  medical  diagnosis.  For  a  consistent 
apprehension  of  the  significance  of  most  of  the  important  physical 
signs  elicited  by  feeling  of  the  chest  walls  (palpation),  sounding 
(percussion),  and  direct  or  instrumental — stethoscopic — listening 
(auscultation),  there  must  be  some  clear  knowledge  of,  for  example, 
the  attributes  of  sounds,  such  as  intensity,  pitch,  quality ;  the  changes 
and  various  effects  in  their  production,  conduction,  and  dissipation 
in  and  over  different  structures  and  organs,  such  as  pertain  to  air- 
containing  and  airless  organs,  bronchial  and  intestinal  tubes;  the 
acoustic  effects  of  increased  density,  as  of  a  morbid  deposit  in  the 
lungs,  of  diminished  elasticity,  of  intervening  normal  or  pathologic 
structures,  and  of  the  presence  abnormally  of  gaseous,  liquid,  and 
solid  substances  upon  the  character  and  propagation  of  sound  waves; 
the  relations  of  the  volume  and  tension  of  membranous  organs  or 
cavities  to  the  pitch,  especially,  of  percussion  vibrations;  and  the 


INTRODUCTION  7 

dependence  of  the  phenomena  of  the  cardiovascular  system  upon  the 
principles  of  hydrodynamics  (hemodynamics?). 

(2)  That  an  accurate  acquaintance  with  at  least  gross  anatomy 
is  a  sine  qua  non  in  the  study  and  practise  of  physical  diagnosis 
needs  but  to  be  mentioned  to  meet  with  ready  assent.     For  how  can 
the  location,  size,  shape,  and  mobility  of  outline  of  physically  de- 
monstrable  organs    be    determined,   with    their    pathologic   changes, 
unless  their  anatomic  relations  to  surface  landmarks,  as  well  as  to 
each  other,  are  clearly  known  ?     "  The  ambition  of  the  student  of 
anatomy  is,  or  should  be,  the  ability  to  see  through  the  body,  per- 
ceiving in  the  mind's  eye  all  the  structures  included  therein,  and  their 
complicated  relations  to  each  other.     This  ability  the  student  must 
gain  somehow,  if  he  is  to  achieve  real  success  in  medicine  or  surgery ; 
for  upon  this  knowledge  are  based  both  physical  diagnosis  and  surgical 
procedure"  (Jackson:  University  of  Missouri),  Journal  Amer.  Med. 
Assn.,  September  21,  1901.     It  should  be  borne  in  mind,  too,  that 
a  knowledge  of  regional  anatomy  is  fundamental  to  the  precise  appli- 
cation of  practically  all  of  the  methods  of  physical  investigation,  and 
especially  of  percussion,  simple  or  auscultatory. 

(3)  As,  in  physical  diagnosis,  we  are  dealing  with  living,  func- 
tioning organs,  though  presumably  diseased  ones,  it  is  plain  that 
physiology  is  likewise  a  basal  branch.    The  normal,  physiologic  func- 
tions of  the  heart  and  lungs  give  rise  to  physical  signs   (normal), 
which  must  be  perceived  and  understood  before  the  abnormal  changes 
can  be  recognized  and  interpreted.    A  familiar,  ready,  and,  as  it  were, 
standard  acquaintance  with  the  pulmonary  and  cardiac  movements 
and  cycles  and  their  sounds,  as  met  with  in  health,  is  an  indispensable 
preparation  to  an  adequate  appreciation  of  abnormal  variations  and 
conditions.     While  there  is  a  large  field  for  post-graduate  original 
work  in  the  domain  of  experimental  physiology,  especially  in  the  study 
of  cardiovascular  phenomena,  at  the  same  time  the  facts  and  laws 
already  established  constitute  an  important  part  of  the  preliminary 
knowledge  in  physical  diagnosis. 

(4)  Following  naturally  the  preceding  requirement  is  the  very 
practical  necessity  of  knowing  not  only  independently  the  physical 
characteristics  of  the  gross  morbid  organic  changes,  but  also,  and 
particularly,  their  more  or  less   definite  relations  to  the   abnormal 
physical  signs  observed  and  elicited  during  life:  a  knowledge  of  the 
ante-mortem  physical  phenomena  should  be  compared  with  that  of 
the  post-mortem  findings.     Modifications  of  the  signs  as  affected  by 
the  various  stages  of  certain  pathologic  processes,  as  in  pulmonary 


8  PHYSICAL    DIAGNOSIS 

tuberculosis,  lobar  pneumonitis,  pericarditis,  etc.,  it  is  also  essential 
to  apprehend.  Neither  can  the  facts  and  laws  of  physics  and  experi- 
mental physiology  be  applied  to  the  explanation  of  the  phenomena  of 
pulmonary  and  cardiac  diseases — and  their  treatment,  also  (Balfour) 
— unless  the  pathology  or  mode  of  their  production  and  the  conse- 
quences of  their  action  upon  the  functions  of  other  and  related  organs 
are  understood. 

(5)  Logic  is  the  fundamental  science  of  all  the  sciences  (scicntia 
scientiarum) ;  the  physiology  of  thought;  and  in  no  part  of  medical 
practise  is  the  logical  training  and  habit  of  mind  more  truly  neces- 
sary and  responsible  than  in  diagnosis.  Physical  diagnosis  and  logic 
are  analogous  and  coterminous  in  that  they  aim  to  apply  clear 
methods,  to  understand  and  prove  the  evidence,  to  prevent  error  and 
fallacy,  and  to  attain  a  knowledge  of  the  nature  of  the  results — their 
significance.  Not  only  upon  alert  and  accurate  observation  does  a 
diagnosis  rest,  but  much  more  upon  normal,  methodical,  right  reason- 
ing: the  signs  must  signify,  the  data  must  be  explained  by  means 
of  logical  inference.  It  is  "  with  the  meaning  side  of  ideas  that  logic 
has  to  do"  (Creighton:  Cornell  University).  Physical  diagnosis 
consists  mainly  of  a  series  of  deductions  from  a  number  of  "  well- 
established  generalities "  (Bain)  yielded  by  the  applicable  sciences 
referred  to  in  the  paragraphs  just  preceding.  No  better  or  more 
common  example  can  be  given  of  the  deductive  method  (by  syllogism) 
than  in  the  case  of  the  diagnosis  of  simple  valvular  heart-murmurs 
by  auscultation. 

So  much  for  the  prerequisites  to  the  study  of  physical  diagnosis. 
On  the  other  hand,  prognosis  and  treatment  are  dependent  upon 
physical  diagnosis,  in  large  measure,  for  the  important  objective 
evidence  it  furnishes  in  pulmonary  and  cardiac  affections  especially. 
For  instance,  in  lobar  pneumonia  the  physical  signs  indicating  exten- 
sion of  congestion  and  consolidation,  or  of  delayed  resolution,  or  of 
diminution  of  the  accentuation  of  the  pulmonary  valve  sound,  are  of 
particular  value  in  estimating  the  probable  course  and  complications, 
and  in  deciding  rationally  and  promptly  upon  the  proper  manage- 
ment of  the  patient.  Again,  the  changed  character  of  a  cardiac 
murmur  and  first,  systolic,  or  ventricular  sound,  the  altered  position 
of  the  apex-beat,  and  lateral  extension  of  percussion  dulness  over  the 
heart  indicative  of  its  more  or  less  acute  dilation,  likewise  present 
opportune  and  important  hints  in  these  respects.  Similarly,  in  other 
diseases,  as  in  the  acute  infectious  fevers,  the  prognosis  and  treat- 
ment often  require  modification  and  extra  cautiousness  of  judgment 


9 

and  exercise  of  skill  because  of  the  thoracic  complications  revealed 
by  the  methods  of  physical  examination. 

Qualifications  for  the  Study  of  Physical  Diagnosis. — Back  of  the 
special  knowledge  and  training  acquired  in  the  fundamentals  lie  the 
advantages  of  a  degree  of  general  equipment  that  cannot  fail  to  be 
of  marked  and  far-reaching  practical  benefit.  This  is  twofold :  phys- 
ical and  psychic.  These  are  necessary  for  the  work  to  be  done  in  the 
corresponding  and  cooperating  processes  of  observation  and  explana- 
tion. Since  the  results  of  physical  examination  depend  entirely  and 
exclusively  upon  the  perceptive  and  ratiocinative  sense-organs  and 
faculties  of  the  physician,  the  finer  and  stronger  these  are  innate, 
and  the  better  developed  and  balanced  their  powers  by  previous  edu- 
cation, the  readier,  broader,  and  sounder  the  diagnosis  arrived  at. 

This  means  that  anatomic  and  functional  deficiencies  of  eye,  ear, 
and  hand  may  prove  to  be  serious  handicaps  in  clinical  work.  Very 
poor  eyesight  from  exaggerated  refractive  and  asymmetric  ocular 
troubles;  partial  deafness  in  one  or  both  ears  or  from  perforated  or 
destroyed  tympanic  membranes ;  and  nerve  degenerations,  finger  losses, 
deformities,  or  disabilities  from  disease,  accident,  or  operation,  how- 
ever slight,  are  more  or  less  drawbacks  to  efficiency. 

Of  course,  even  with  physical  wholeness  and  robustness,  naturally 
some  are  more  talented,  have  keener  sense-perceptions  than  others. 
Nevertheless,  though  not  every  one  can  inherit,  cultivate,  and  manifest 
the  exquisite  acumen  and  precision  of  a  Flint  or  Osier,  a  DaCosta 
or  Loomis  or  Pepper,  the  personal  equation  of  every  one  can  be  won- 
drously  improved  by  attentive,  earnest,  patient,  persistent,  thorough- 
going practise.  To  this  end  the  student  will  realize  that  previous 
manual  training  and  habits  of  accurate  observation  in  the  study  of 
the  natural  sciences,  such  as  zoology,  biology,  mineralogy,  botany,  and 
chemistry,  are  invaluable  requisites.  In  physical  diagnosis,  just  as 
in  the  generalizations  from  the  phenomena  of  natural  objects,  organ- 
isms, and  experiments,  we  essay  to  observe  closely  by  comparison — 
especially  in  the  detection  of  abnormalities  and  asymmetries — to  ana- 
lyze or  relate,  and  to  classify  and  interpret.  Obviously,  the  perceptive 
powers  cultivated  in  field  and  laboratory,  the  technical  skill  acquired 
in  handling  instruments  of  precision,  and  systematic  procedures 
thereby  inculcated  and  ingrained  are  hardly  less  than  absolutely  nec- 
essary modern  conditions  of  intellectual  preparedness  for  successful 
results  in  this  most  objective  department  of  general  medical  diagnosis. 

The  benefits  from  the  study  and  practise  of  physical  diagnosis 
bear  the  same  sequential  relation  to  professional  progress  in  diagnostic 


10  PHYSICAL   DIAGNOSIS 

skill  and  inference  that  those  do  to  preparatory  education  which  are 
developed  and  acquired  in  attaining  the  qualifications  for  the  study 
of  physical  diagnosis.  The  eye,  ear,  and  hand  become  more  highly 
sensitive  and  specialized,  the  prompt  concentration  and  circumscrip- 
tion of  attention  are  sharpened,  and  the  inferences  derived  from 
reasoning  upon  the  results  of  observation  are  facilitated,  and  their 
consistency  and  probability  enhanced.  A  fortiori,  the  work  and  relia- 
bility of  medical  diagnosis  in  general  are  furthered  and  established 
by  so  much :  perspicacity  becomes,  as  it  were,  a  professional  habit  at 
all  times. 


PART    I 

THE  CHEST  (THORAX) 


PLATE    I 


ANTERIOR  ASPECT.     SHOWS  THE  NORMAL  POSITION  AND  RELATIONS  OF  THE  LUNGS 
AND  HEART  TO  EACH  OTHER  AND  TO  THE  BONY  THORAX. 


SECTION"    I 

METHODS  AND   TECHNIC:  PHYSICAL   SIGNS 
AND   DIAGNOSIS   IN   GENERAL 


CHAPTER    I 
TOPOGRAPHIC  AND  RELATIONAL  ANATOMY  OF  THE  CHEST 

NEXT  to  the  actual  detection  of  physical  signs,  the  most  important 
diagnostic  point  is  their  anatomic  localization.  However,  as  some 
knowledge  of  the  surface  anatomy  in  relation  to  the  underlying 
organs  is  fundamental  to  the  development  of  the  methods  of  physical 
examination,  the  topography  of  the  chest  will  he  considered  first.  It 
is  assumed  that  the  student  is  tolerably  familiar  with  the  descriptive 
anatomy  of  the  heart  and  lungs,  and  with  such  elemental  physical 
characteristics  as  their  situation,  size,  shape,  density,  contiguity,  etc. 
(See  Introduction.) 

For  localizing  physical  signs  as  precisely  as  possible  we  utilize 
partly  the  more  or  less  obvious  anatomic  spaces  and  prominences 
(landmarks) ;  and  partly,  local  regions  outlined  arbitrarily,  and  yet 
as  naturally  and  conveniently  as  may  be,  by  the  use  of  certain  lines 
conceived  as  drawn  upon  the  surface  of  the  chest.  It  is  of  great 
importance,  in  general  as  well  as  in  physical  diagnosis,  that  an  accu- 
rate knowledge  of  thoracic  landmarks  be  obtained,  as  it  assures  accu- 
racy in  locating  the  diseased  parts  or  organs  by  the  principal  means — 
i.  e.,  the  surface  indications. 

Such  knowledge  is  also  necessary  in  any  intelligent  description  of 
the  site  of  lesions,  whether  in  recitation,  clinical  conference  or  con- 
sultation, discussion  or  written  article ;  and  likewise  in  describing  and 
recording  changes  of  position,  and  of  extent  and  direction  of  the 
boundaries  of  organs.  This  holds  true  whether  the  description  refers 
merely  to  an  approximate  designation,  as  of  a  region,  or  to  the  more 
accurate  pointing  to  a  numbered  rib  or  interspace,  or  measured  rela- 
tion to  another  recognized  anatomical  prominence  or  arbitrary  line. 

13 


14  PHYSICAL    ])IA(i.\OSIS 


ANATOMIC    LANDMARKS    OF    THE    CHEST 

(1)  Clavicle. — Starting  on  the  front  of  the  thorax,  from  above, 
are  these  double-curved  bones,  the  clavicles,  prominent  dividing  lines 
between  the  neck  and  chest  (and  supra-  and  infraclavicular  regions), 
affording  fixation  points  for  measurements,  and  covering  the  first  rib 
on  either  side. 

(2)  Sternum. — At  the  top  of  the  breast-bone  is  the  suprastcmal 
notch,  on  a  level  with  the  disk  between  the  second  and  third  dorsal 
vertebrae. 

Passing  downward  from  the  notch,  about  one  and  one-half  inches 
below,  is  a  transverse  ridge  or  projection,  slight  but  distinct,  the 
angle  of  Louis  (Angulus  Ludovici).  It  is  formed  by  the  junction 
of  the  manubrium  with  the  body  of  the  sternum,  is  practically  always 
to  be  seen  and  felt  in  every  individual  (less  so  in  females  and  in 
the  obese),  and  affords  an  infallible  guide  in  the  counting  of  ribs, 
as  it  corresponds  with  the  middle  of  the  cartilage  of  the  second 
rib.  It  is  also  on  a:  plane  with  the  body  of  the  fifth  dorsal 
vertebra. 

At  the  lower  end  of  the  sternum  is  the  slight  depression  caused 
by  the  dipping  backward  (variable)  of  the  ensiform  or  xiphoid  appen- 
dix below  its  junction  with  the  body  (gladiolus)  of  the  sternum. 
Sometimes  it  curves  and  projects  forward  so  that  its  tip  forms  a 
email  nodule,  or  nipple-like  eminence.  The  sternoxiphoid  junction 
is  nearly  on  a  line  with  the  disk  between  the  ninth  and  tenth  dorsal 
vertebrae. 

(3)  Ribs  and  Intercostal  Spaces. — METHOD  or  COUNTING  BIBS. — 
Kibs  are  the  most  commonly  used  bony  landmarks  in  all  physical 
examinations  of  the  chest.     To  know  them  and  count  them,  there- 
fore, requires  constant  practise,  so  that  ready  familiarity  in  localiza- 
tion may  be  attained. 

As  pointed  out  above,  the  angle  of  Louis  is  always  a  reliable 
starting-point,  the  finger  running  along  horizontally  over  the  second 
rib  on  either  side,  the  number  of  any  particular  rib  being  then  de- 
termined by  counting  downward  and  feeling  somewhat  obliquely  out- 
ward at  the  same  time.  Any  desired  rib  may  be  followed  thus  into 
the  axilla,  and  backward  and  slightly  upward  posteriorly  toward  the 
spine. 

As  noted  by  Holden,  the  fifth  rib  corresponds  in  direction  to  the 
lower  external  border  of  the  pectoralis  major. 


PLATE    II 


ANTERIOR  ASPECT.     SHOWS  THE  CARDIAC  RELATIONS  WITH  THE  LUNGS  REMOVED. 


ANATOMY    OF    THE    CHEST  15 

Again,  a  line  drawn  horizontally  from  the  nipple  round  the  chest 
cuts  the  sixth  intercostal  space  midway  (midaxillary  line)  between 
the  sternum  and  the  spine — a  useful  rule  in  tapping  fluid  from  the 
chest. 

Furthermore,  when  the  arm  is  raised  horizontally  or  a  little  above, 
the  highest  visible  digitation  of  the  serratus  magnus  corresponds  with 
the  sixth  rib.  The  two  digitations  below  this  lie  over  the  seventh  and 
eighth  ribs  respectively. 

The  eleventh  and  twelfth  ribs  can  be  felt  when  the  abdominal  wall 
is  relaxed,  even  in  short  persons.  They  slope  downward  and  forward 
outside  the  erector  spins  muscles. 

It  is  this  downward  slope  which  makes  the  sternal  ends  of  all  the 
ribs  lower  than  their  vertebral  articulations.  Thus,  the  third  chondro- 
sternal  junction  is  on  a  level  with  the  body  of  the  sixth  dorsal  verte- 
bra. Below  this,  to  the  seventh  rib  inclusive,  by  adding  four  to  the 
number  of  the  rib  in  front,  its  relative  level  with  the  corresponding 
costovertebral  articulation  behind  is  immediately  known;  for  exam- 
ple, the  fifth  rib  anteriorly  corresponds  with  the  level  of  the  ninth 
rib  posteriorly,  and  so  on. 

Upon  the  back,  points  of  height  are  also  determined  by  rib- 
counting,  though  here  it  is  manifestly  more  difficult,  especially  in 
the  corpulent. 

(a)  The  tips  of  the  vertebral  spines  may  serve  as  guides,  begin- 
ning with  the  vertebra  prominens,  or  seventh  cervical,  immediately 
below  which  the  first  rib  begins;  then  the  second  rib,  articulating 
with  the  second  and  third  dorsal  vertebrae,  and  so  on  downward,  ex- 
cepting the  tenth,  eleventh,  and  twelfth  ribs,  which  articulate  with 
their  respective  numbered  dorsal  vertebra  only.  A  caution  is  advis- 
able here.  Owing  to  their  downward  projection,  most  of  the  dorsal 
spinous  processes  are  on  a  level  with  the  next  numbered  rib  below: 
thus,  the  second  dorsal  spine  corresponds  with  the  third  rib,  and  the 
ninth  spine  to  the  tenth  rib;  the  intervening  spines  and  ribs  accord- 
ingly ;  the  tenth  spine,  shorter  and  less  inclined,  is  between  the  tenth 
and  eleventh  ribs ;  the  last  two  ribs,  like  the  first  one,  correspond  with 
their  respective  numbered  vertebral  spines. 

(&)  The  Seventh  Eib. — This  lies  under  the  lower  angle  of  the 
scapula  in  easy  positions  of  the  chest,  with  the  arms  resting  against 
the  chest  and  the  forearms  hanging  or  folded  lightly.  Hence  the 
ribs  may  be  counted  posteriorly  from  this  point  of  the  scapula  repre- 
senting the  position  of  the  seventh  rib. 

(c)   The  twelfth  rib  may  readily  be  felt  behind  at  its  tip  espe- 


16  PHYSICAL   DIAGNOSIS 

cially,  in  most  people,  and  affords  a  starting-point  for  counting  the 
lower  ribs  upward. 

The  intercostal  spaces  lie  below  their  corresponding  numbered 
ribs.  The  first  and  second  intercostal  spaces  are  readily  recognized, 
one  above,  the  other  below,  the  level  of  the  angle  of  Louis.  The 
second  and  third  interspaces  are  usually  the  widest,  and  in  fact  all 
the  interspaces  are  wider  anteriorly  than  laterally  and  posteriorly. 

(4)  Epigastric  Angle. — This  is  the  angle  pointing  upward  at  the 
xiphoid  cartilage,  and  is  formed  on  its  sides  by  the  lower  borders 
of  the  converging  and  coalescing  lower  ribs.     It  is  normally  and 
nearly,   in  the   average  person,  a  right  angle  during  moderate  or 
ordinary    breathing;   with    deeper    respiration,    the   ribs   rising   and 
falling,  the  angle  varies,  being  somewhat  more  obtuse  at  the  end 
of    a   full    inspiration,   with   the   ribs   more    horizontal,    and    more 
acute  at   the  end  of  deep  expiration,  when  the  ribs   slant  down- 
ward more. 

(5)  Nipple. — This  prominent  landmark  is  not  a  strictly  reliable 
one  for  constancy  and  accuracy  in  localization,  especially  in  females, 
where  the  size,  shape,  and  pendulousness  of  the  mammary  gland  are 
inevitably  and  naturally  so  variable.    And,  although  in  the  male  even 
its  position  is  not  infrequently  anomalous,  here  it  is  sufficiently  con- 
stant, in  a  majority  of  instances,  at  least,  to  be  a  fairly  good  point 
for  localization,  as  it  usually  lies  over  the  fourth  rib  or  interspace, 
sometimes  over  the  fifth  rib,  less  commonly  over  the  fifth  interspace; 
or  about  three-fourths  of  an  inch  external  to  the  cartilages,  or  about 
four  inches  from  the  middle  of  the  sternum. 

(6)  Mammary  Gland. — This  gland  aids  in  localizing   physical 
signs  principally  in  giving  nominal  designation  to  its  region,  extend- 
ing horizontally  from  the  sternal  border  to  the  anterior  boundary  of 
the  axilla.    Vertically,  its  circumferential  attachment  reaches  usually 
from  the  third  to  the  sixth  rib  or  interspace  inclusive. 

(7)  Scapula. — This  prominent  bone  lies  on  the  back  from  the 
second  to  the  seventh  ribs  inclusive.     The  inner  end  of  the  spine  of 
the  scapula  is  on  a  level  with  the  third  dorsal  spine,  and  the  inferior 
scapular  angle  with  the  seventh. 

(8)  Spine. — The  median  groove  or  furrow  is  distinct  in  all.     In 
its  middle  are  the  spinous  processes,  visible  by  the  slight  bulgings  of 
the  skin  over  them,  except  in  fat  individuals.    They  may  be  counted 
best  palpably  by  the  aid  of  position  or  friction :  either  by  having  the 
patient  bend  forward,  the  convexity  of  the  spine  causing  the  processes 
to  separate  and  stand  out  more,  or  by  rubbing  briskly  up  and  down 


PLATE    III 


POSTERIOR  ASPECT.     LANDMARK  RELATIONS  OF  THE  LUNGS  VIEWED  FROM  THE  BACK. 


ANATOMY    OF    THE    CHEST  17 

over  them  with  the  finger  or  towel,  their  tips  then  showing  bright 
spots  of  redness. 

The  spines  of  the  second,  third,  fourth,  fifth,  and  sixth  cervical 
vertebra?  are  scarcely  recognizable  separately,  but  the  seventh  or  ver- 
tebra prominens,  as  hinted  before,  is  a  distinct  landmark  for  counting 
and  localizing  point  of  vantage.  The  twelfth  dorsal  spine  may  be 
located  also  by  following  in  from  the  twelfth  rib,  the  tip  of  which 
may  be  felt,  when  the  lumbar  muscles  are  relaxed,  about  three  inches 
from  the  median  furrow. 


TOPOGRAPHIC    REGIONS    OF    THE    CHEST    AND 
RELATIONAL    ANATOMY 

The  recent  tendency  to  amend  the  old  nomenclature  of  the  divi- 
sions of  the  chest  made  by  certain  arbitrary  lines  conceived  as  drawn 
upon  its  surface,  and  in  which  physical  signs  were  to  be  referred 
accordingly,  is  characteristic  of  progress  in  method  toward  a  com- 
mendable simplicity,  desirable  accuracy,  and  judicious  flexibility  of 
application.  I  agree  with  several  recent  clinical  authors  that  it  is 
much  wiser  to  refer  physical  data  to  bony  anatomic  landmarks,  such 
as  given  just  previously,  using  measurements  at  times;  and  to  divide 
the  chest  into  regions  corresponding  only  or  principally  to  natural  or 
anatomical  outlines.  Nevertheless,  it  so  happens  that  most  of  the 
arbitrarily  divided  regions  are  really  appropriately  named  on  this 
basis.  Hence,  and  in  order  that  the  student  may  have  an  intelligent 
acquaintance  with  the  designated  areas  as  still  widely  used  in  medical 
literature,  they  are  given  here  with  sufficient  fulness.  The  lines 
auxiliary  to  a  description  of  these  regions  are  given  first. 

ARBITRARY  LINES  AS  LANDMARKS 

These  are  to  be  used  rather  as  guide  lines  of  reference,  therefore, 
and  not  for  a  rigid  sort  of  geometric  mapping  out  of  the  thoracic 
surface.  The  natural  folds  and  furrows  and  fulnesses  are  simpler 
and  practically  sufficient  as  boundary  lines.  For  determining  points 
of  height,  however,  the  clavicle,  ribs,  and  vertebral  spines  are  better 
than  the  seven  or  more  imaginary  horizontal  or  latitudinal  lines 
usually  drawn.  For  determining  the  breadth,  certain  vertical  or 
longitudinal  lines  are  often  useful  and  commonly  used  as  reference 
lines  in  recording  and  describing  physical  signs  and  measurements 
of  localization. 


18  PHYSICAL   DIAGNOSIS 

These  vertical  lines  are  as  follows: 

Anteriorly,   (1)   The  mesosternal  (midsternal)  line,  the  middle  line 
of  the  sternum. 

(2)  The  sternal  lines,  right  and  left,  corresponding  to 
the  side  margins  of  the  sternum. 

(3)  The  parasternal  lines,  midway  between  the  sternal 
and  the  next,  or 

(4)  The  mamrnillary  lines,  passing  through  the  nipples. 
Laterally,      (5)   The  anterior  axillary  lines,  through  the  points  where 

the  great  pectoral  muscles  leave  the  chest,  when  the 
arms  are  raised  to  the  horizontal. 

(6)  The  mesoaxillary  (midaxillary)  lines,  drawn  through 
the  middle  of  the  axilla,  or  midway  between  the  an- 
terior and 

(7)  The  posterior  axillary  lines,  running  through   the 
points  where  the  latissimus  dorsi  muscles  leave  the 
chest. 

Posteriorly,  (8)   The   scapular   lines,    passing    through   the   inferior 

angles  of  the  scapula?. 

(9)   The  mesospinal  (midspinal)   line,  through  the  ver- 
tebral spines. 

Of  these,  by  far  the  most  important  practically  are  the  mesosternal 
line,  the  mammillary  line  on  either  side  when  it  coincides  with  a  line 
passing  through  the  center  of  the  clavicle  (mesoclavicular  or  midcla- 
vicular  line),  the  mesoaxillary  lines,  and  the  mesospinal  line. 

The  vertical  nipple  lines  are  not  always  reliable  lines  of  reference 
because  of  the  variability  of  the  position  of  the  nipple,  especially  in 
women,  though  by  no  means  constant  in  men;  hence,  owing  to  the 
fixed  position  of  the  clavicle,  the  mesoclavicular  line  is  more  depend- 
able, which,  in  the  majority  of  individuals,  nevertheless,  does  coincide 
with  the  mammillary  line;  therefore  the  frequent  use  of  the  latter 
term  in  practise. 

REGIONS 

ANTERIOR  ASPECT 

(1)  Starting  above  and  in  the  middle,  the  first  space  noticed  is 
the  suprasternal  depression  or  region,  just  above  the  suprasternal 
notch,  and  bounded  laterally  by  the  inner  borders  of  the  sternomastoid 
muscles. 


PLATE    IV 


LATERAL  ASPECT  (RIGHT).     TOPOGRAPHIC  RELATIONS  OF  RIGHT  LUNG  AND  LIVER  IN 
THE  INFERIOR  AXILLARY  REGION. 


ANATOMY    OF    THE    CHEST 


19 


RELATIONAL  ANATOMY. — The  suprasternal  region  is  occupied 
mainly  by  the  trachea;  pathologically  it  may  be  encroached  upon  by 
an  aneurismal  dilation  of  the  aortic  arch. 

(2)  Supraclavicular  Regions. — These  triangular  spaces  are  directly 
above  the  clavicles  (inner  two- thirds),  bounded  anteriorly  by  the 
sternomastoids  and  posterolaterally  by  the  trapezius  muscle  borders. 

RELATIONAL  ANATOMY. — Beneath  these  regions,  on  either  side, 
are  the  lung  apices  (toward  the  inner  thirds  of  the  clavicles),  portions 


ANTERIOR 
AXILLARY  LINE 

MAMMILLARY  LINE 


PARASTERNAL 
LINE 


STERNAL  LINE 


FIG.  1. — SHOWING  THE  TOP 


HICAL  AREAS  OF  THE  THORAX  ANTERIORLY. 
(Butler.) 


of  the  subclavian  and  carotid  arteries,  and  of  the  subclavian  and  jugu-' 
lar  veins.  The  apex  of  the  lung  may  rise  from  one-half  to  one  and 
three-fourths  inches  above  the  upper  clavicular  border;  the  left  apex 
is  more  frequently  a  little  higher  than  the  right.  The  first  rib  forms 
a  part  of  the  floor  of  this  region.  Just  above  the  inner  portion  of 
the  clavicle  the  subclavian  artery  pulsations  may  be  felt. 

(3)  Clavicular  Region. — This  represents  practically  the  margins 
of  the  inner  two-thirds  of  the  clavicle. 

RELATIONAL  ANATOMY. — Behind  it  is  the  lung  apex  on  either 
side.  On  the  right  side,  at  the  sternal  articulation,  lies  the  bifurca- 


20  PHYSICAL   DIAGNOSIS 

tion  of  the  innominate  artery  and,  more  externally,  the  subclavian 
artery.  On  the  left  side,  the  carotid  and  subclavian  arteries  lie  more 
deeply. 

(4)  Infraclavicular  Regions. — Situated  just  below  the  clavicles, 
these  spaces   have  no  distinct  lower  boundaries,   though  somewhat 
naturally  ending  where  the  upper  borders  of  the  mammary  glands 
begin — i.  e.,  at  the  third  rib  level.     Internally  they  are  bounded  by 
the  borders  of  the  sternum,  and  externally  by  a  vertical  line  passing 
through  the  "  acromial  angle"  (formed  by  the  clavicle  and  the  head 
of  the  humerus).     Morenheim's  depression  is  felt  in  this  angle,  and 
is  sometimes,  though  not  commonly,  used  as  a  reference  in  the  local- 
ization of  physical  signs.     Sibson's  furrow,  also,  may  be  used.     It 
represents  the  lower  border  of  the  pectoralis  major. 

RELATIONAL  ANATOMY. — Besides  the  upper  lobes  of  the  lungs, 
the  infraclavicular  fossae  contain  the  following:  on  the  right  side, 
close  to  the  sternal  border,  lie  the  superior  vena  cava  and  a  part  of 
the  aortic  arch,  while  the  right  bronchus  is  directly  behind  the  second 
costal  cartilage;  on  the  left  side,  the  pulmonary  artery  (edge  of  the 
sternum),  left  auricle — second  interspace,  behind  the  lung — and  left 
bronchus  are  situated,  the  last  named  a  little  below  the  second  costal 
cartilage. 

(5)  Mammary  Regions. — Extending  from  the  third  to  the  sixth 
ribs,  as  do  the  glands  because  of  which  these  areas  are  named,  they 
are  also  bounded  internally  and  externally  as  those  preceding.     The 
nipples  have  already  been  described  as  landmarks. 

RELATIONAL  ANATOMY. — The  contents  differ  materially  on  the 
two  sides  as  related  to  these  regions.  On  the  right  side  are  the  lung, 
dome  of  the  liver,  right  border  of  the  heart,  and  diaphragm.  The 
hmg  lies  superficially  throughout  this  region,  its  lower  edge,  in  fact, 
corresponding  to  the  lower  boundary  (sixth  rib)  of  the  region.  The 
deeply  situated  right  wing  of  the  diaphragm  and  right  lobe  of  the 
liver  rise  to  the  level  of  the  fourth  interspace.  The  fissure  between 
the  upper  and  middle  lobes  of  the  lung  passes  obliquely  upward  and 
backward  from  about  the  fourth  cartilage;  that  between  the  middle 
and  lower  in  the  same  direction  from  the  fifth  interspace.  A  portion 
of  the  right  auricle  and  right  ventricle,  covered  by  lung,  lie  close  to 
the  sternum,  extending  very  little  from  behind  its  right  border,  be- 
tween the  third  and  sixth  costal  cartilages. 

On  the  left  side  the  mammary  region  is  occupied  mainly  by  the 
heart,  partly  covered  by  lung,  the  anterior  edge  of  which  passes  ob- 
liquely downward  and  outward  from  about  the  level  of  the  fourth 


PLATE    V 


TOPOGRAPHIC  RELATIONS  (LEFT  LATERAL  ASPECT)  OF  THE  LEFT  LUNG  AND  SPLEEN, 
INFERIOR  AXILLARY  REGION. 


ANATOMY    OF    THE    CHEST  21 

cartilage  to  the  fifth  rib,  thence  curving  somewhat  inward  and  down- 
ward to  the  sixth  rib,  within  the  vertical  midclavicular  line.  The 
quadrilateral  free  space  thus  left  is  directly  over  the  right  ventricle. 
A  portion  of  the  right  auricle,  and  the  deeply  seated  left  auricle  and 
ventricle  (apex  in  the  fifth  interspace  inside  the  midclavicular  line), 
also  occupy  this  region.  The  anterior  end  of  the  -fissure  between  the 
upper  and  lower  lobes  of  the  left  lung  lies  behind  the  sixth  rib  in  the 
vertical  nipple  line. 

(())  Inframammary  Regions. — These  naturally  extend  downward 
from  the  sixth  ribs  to  the  edges  of  the  false  ribs;  laterally,  from  the 
prolonged  outer  border  of  the  mammary  region  to  the  sternum  at 
the  epigastric  angle  or  top  of  the  costal  arch. 

BELATIONAL  ANATOMY. — On  the  right  side,  the  liver,  covered  by 
the  diaphragm,  and  during  deep  inspiration  encroached  upon  by 
the  lower  border  of  the  lung  in  the  sixth  or  seventh  interspaces,  are  in 
relation.  Normally,  the  lower  border  of  the  liver  coincides  with  the 
costal  edge  of  the  thorax,  in  the  midclavicular  line,  before  reaching 
obliquely  upward  and  to  the  left  in  crossing  the  median  line  at  a 
point  less  than  halfway  downward  between  the  ensiform  cartilage 
and  the  navel.  On  the  left  side,  the  lower  edge  of  lung  extends  in 
the  upper  and  outer  portion  of  this  region  during  full  inspiration. 
The  left  lobe  of  the  liver  occupies  the  inner  part,  lying  in  front  of 
the  stomach  (cardiac  end). 

Although  the  epigastric  region  lies  between  the  inframammary 
regions,  within  the  borders  of  the  costal  arch,  its  relational  anatomy 
is  properly  a  part  of  abdominal  topography  and  physical  diagnosis, 
and  will  be  considered  under  that  head. 

(7)  Superior  Sternal  Region. — Anatomically,  this  corresponds  to 
the  borders  of  the  manubrium,  although  most  authors  extend  it  below 
the  angle  of  Louis    (the  junction  landmark  with  the  body  of  the 
sternum)  to  the  dividing  line  between  the  infraclavicular  and  mam- 
mary regions  on  a  level  with  the  third  costal  cartilages. 

EELATIONAL  ANATOMY. — Here  are  found  the  inner  edges  of  the 
lungs  below  the  level  of  the  second  costal  cartilages;  the  bifurcation 
of  the  trachea  opposite  the  angle  of  Louis;  the  aortic  arch  (ascending 
and  transverse  portions)  and  pulmonary  artery,  with  their  respective 
valves;  the  left  innominate  vein,  and  a  part  of  the  descending  vena 
cava. 

(8)  Inferior  Sternal  Region. — Corresponding  to  the  remainder 
of  the  sternum,  this  region  contains  the  edge  of  the  right  lung  de- 
scending vertically  along  the  middle  line,  and  at  its  upper  part  a 


22  PHYSICAL   DIAGNOSIS 

small  portion  of  the  left  lung;  a  major  part  of  the  right  ventricle 
and  origin  of  the  pulmonary  artery ;  a  small  part  of  the  left  ventricle 
behind,  with  the  origin  of  the  aorta;  a  part  of  the  right  auricle,  of 
the  liver,  and  of  the  pericardial  attachment  of  the  diaphragm. 

LATERAL  ASPECTS 

(9)  Axillary   Regions. — These  extend   from   the  points   of   the 
axillae  above  to  the  level  of  the  lower  borders  of  the  mammary  re- 
gions below  (sixth  rib  anteriorly) ;  anteriorly  and  posteriorly  by  lines 
drawn  through  the  insertions  of  the  anterior  and  posterior  folds  of 
the  axilla?  (where  the  pectoralis  major  and  latissimus  dorsi  muscles 
leave  the  thorax),  as  seen  when  the  arms  are  raised  sidewise  to  the 
horizontal  (anterior  and  posterior  axillary  lines). 

RELATIONAL  ANATOMY. — On  both  sides  are  lung  tissue,  and, 
deeper,  the  bronchi  and  larger  bronchial  branches. 

(10)  Infra-axillary  Regions. — They  are  bounded  above  by  the  ax- 
illary regions;  below,  by  the  margins  of  the  false  ribs;  anteriorly,  by 
the  external  boundary  of  the  inframammary  regions;  posteriorly,  by 
the  infrascapular  regions  (at  the  posterior  axillary  lines). 

RELATIONAL  ANATOMY. — On  the  right  side,  the  lung  with  its  lower 
border  sloping  downward  and  backward  to  the  eighth  rib  in  the  mid- 
axillary  line,  and  below,  to  nearly  the  edge  of  the  thorax,  the  liver, 
are  contained.  On  the  left  side,  in  addition  to  the  similarly  placed 
lung,  are  the  stomach  and  spleen. 

POSTERIOR  ASPECT 

(11)  Suprascapular  Regions. — The  boundaries  are  those  of  the 
small,  circumscribed,  flattened  areas  immediately  above  the  scapular 
spines,  and  limited  above  by  the  borders  of  the  trapezius  muscles. 
They  correspond  to  the  supraspinous  fossa?  of  the  shoulder  blades. 

RELATIONAL  ANATOMY. — The  apices  of  the  lungs  are  in  relation 
here,  which  marks  these  regions  of  great  importance  in  the  detection 
of  incipient  tuberculosis. 

(12)  Scapular  Regions. — They  correspond  to  the  outlines  and 
spaces  of  the  infraspinous  fossae  of  the  scapulae. 

RELATIONAL  ANATOMY. — Lung  tissue  and  the  main  lobar  fissures 
are  opposite  these  regions. 

(13)  Infrascapular  Regions. — They  are  bounded  above  by  the 
level  of  the  inferior  angles  of  the  scapular  bones ;  below,  by  the  edge 
of  the  thorax;  posteriorly  (inside),  by  the  dorsal  spines  below  the 


PLATE    VI 


#>  ^  >  X  *S? 


BONY  LANDMARKS  OF  THE  ANTERIOR  SURFACE  OF  THE  CHEST,  WITH  THE  VERTICAL 
LINES  FOR  MEASUREMENT  AND  REFERENCE. 


ANATOMY    OF    THE    CHEST 


23 


seventh  vertebra;  anterolaterally  (outside),  by  the  posterior  borders 
of  the  infra-axillary  regions — at  tbe  vertical  lines  through  the  points 
at  which  the  latissimi  dorsi  muscles  leave  the  chest. 

RELATIONAL  ANATOMY. — Just  below  the  surface,  on  both  sides, 
are  the  lungs,  their  borders  extending  downward  as  far  as  the  eleventh 


FIG.  2. — SHOWING  THE  TOPOGRAPHICAL  AREAS  OF  THE  TRUNK  POSTERIORLY.   (Butler.) 

ribs.  On  the  right  side,  below  the  lung  border,  lies  the  uncovered 
narrow  strip  of  liver,  and,  close  to  the  spine,  the  upper  portion  of 
the  right  kidney.  On  the  left  side,  from  the  backbone  outward,  are 
aorta,  kidney,  intestine,  and  spleen. 

(14)  Interscapular  Region. — This  occupies  the  space  between  the 
shoulder  blades,  and  from  the  second  to  the  seventh  dorsal  spines — 
the  latter  at  the  level  of  the  inferior  angles  of  the  scapula?. 

RELATIONAL  ANATOMY. — On  both  sides  this  region  contains  lung 
substance,  the  main  bronchi  (bifurcation  at  the  fourth  dorsal  verte- 


24  PHYSICAL   DIAGNOSIS 

bra),  and  the  bronchial  glands.  On  the  left  side  it  also  contains  the 
descending  aorta  (from  the  third  or  fourth  dorsal  vertebra),  esopha- 
gus, and  thoracic  duct. 


RELATIONAL    ANATOMY    (LANDMARKS)    OF 
THE    LUNGS 

Before  taking  up  the  physical  methods  of  examining  the  lungs, 
it  is  needful  to  know  certain  definite  facts  in  connection  with  the 
surface  relations  of  the  boundaries,  limits,  fissures,  and  lobes  of  the 
lungs;  and  also  points  bearing  upon  the  position  and  extent  of  the 
pleural  sacs.  There  are  important  differences  between  the  two  sides, 
although  on  both  sides  the  lungs  are  everywhere  in  contact  with  the 
thoracic  wall,  except  in  the  neighborhood  of  the  heart  and  behind 
a  small  portion  of  the  upper  part  of  the  sternum,  and  they  both 
reach  from  their  apices  to  the  sixth  ribs  in  front  and  to  the  tenth 
behind. 

Right  Lung  (see  accompanying  figures). — UPPER  LIMIT:  The 
apex  projects  into  the  supraclavicular  region  from  three-fourths  to 
one  and  three-fourth  inches  (2  to  5  cm.)  above  the  clavicle,  in  front; 
behind,  as  high  as  the  level  of  the  seventh  cervical  spinous  process. 

MEDIAN  LIMIT:  Somewhat  to  the  left  of  the  median  line  of  the 
sternum,  behind  the  angle  of  Louis,  to  which  landmark  the  anterior 
border  converges  (downward,  forward,  and  inward)  from  the  apex. 
It  continues  thus  to  the  fourth  chondral  level,  then  gently  outward 
and  downward  to  the  sternal  insertion  of  the  sixth  costal  cartilage, 
whence  it  passes  more  abruptly  outward  to  the 

LOWER  LIMIT:  The  now  lower  border  here  follows  the  sixth  rib 
to  the  mammillary  line,  then  nearly  horizontally  backward  intersects 
the  eighth  rib  in  the  middle  axillary  line,  the  tenth  rib  in  the  scapular 
line,  and  reaches  the  level  of  the  eleventh  dorsal  spine  near  the  verte- 
bral column. 

POSTERIOR  LIMIT  :  This  corresponds  to  the  vertebral  border,  run- 
ning nearly  parallel  to  the  spine  from  the  latter  limit  to  the  apex 
just  below  the  border  of  the  trapezius  in  front.  Practically,  it  has 
been  customary  for  me  to  indicate,  as  an  aid  to  memory,  the  even 
numbers  of  the  ribs  passed,  as  follows:  second,  fourth,  sixth  ribs 
(front),  eighth  rib  (side),  tenth  rib  (back). 

Left  Lung. — The  limits  are  relatively  the  same,  except  that  the 
left  apex  is  apt  to  rise  a  trifle  higher,  and  the  inferior  border  to 


PLATE  VII 


LANDMARKS  AND  LINES  OF  THE  LATERAL  SURFACE  OF  THE  CHEST. 


25 


reach  a  trifle  lower,  than  the  right.  The  only  important,  and  at  the 
same  time  characteristic,  difference  is  in  the  notchlike  course  of  the 
anterior  border  between  the  fourth  and  fifth  ribs  directly  over  the 
right  ventricle  of  the  heart.  From  the  sternal  end  of  the  fourth 
cartilage  this  border  curves  sharply  outward  and  downward  behind  the 
fourth  interspace  to  a  little  beyond  the  parasternal  line,  then  slightly 
inward  to  the  fifth  interspace,  and  again  bending  abruptly  downward 
and  outward  to  cross  under  the  sixth  rib  in  the  mammillary  line,  as  on 
the  right  side :  the  lingula  of  the  lung,  so-called,  is  thus  formed. 

Fissures  of  the  Lungs. — A  knowledge  of  the  fissures — their  land- 
marks— though  of  secondary  importance,  is  sufficiently  needful  be- 
cause of  the  lobes  into  which 
they  divide  the  lungs.  This 
is  especially  true  in  cases  of 
lobar  pneumonia,  where  the 
limitation  or  progress  of 
the  disease  to  one  or  more 
lobes  may  thus  be  recog- 
nixcd  by  the  boundary  rela- 
tions of  the  physical  signs. 

FISSURES  OF  THE  RIGHT 
LUNG. — The  Long  or  Great- 
er Fissure.— It  separates  the 
middle  and  upper  lobes  from 
the  lower.  Its  starting-point 
posteriorly  is  at  the  verte- 
bral border  of  the  lung  at 
about  the  level  of  the  inner 
end  of  the  spine  of  the  scap- 
ula (third  dorsal  vertebra). 
Its  direction  is  obliquely 

downward  and  forward,  passing  behind  the  fourth  rib  in  the  mid- 
axillary  line,  and  terminating  at  the  antero-inferior  edge  of  the  lung 
at  the  sixth  rib  in  the  mammillary  line. 

The  short  or  lesser  fissure  branches  off  from  the  preceding  at 
or  near  the  outer  border  of  the  scapula  and  third  interspace,  and 
passes  nearly  horizontally  forward,  and  ends  at  the  anterior  edge  of 
the  lung  under  the  fourth-rib  insertion,  thus  dividing  the  upper  from 
the  middle  lobe. 

FISSURE  OF  THE  LEFT  LUNG. — This  one  fissure,  separating  the 
upper  from  the  lower  lobe,  starts,  courses  in  the  same  direction,  and 


LOWE 
PLEURA 


FIG.  3. — SHOWING  THE  LOBES  OF  THE  LTINO 
AND  THE  LOWER  LIMIT  OF  THE  PLEURA  ON 
THE  RIGHT  SIDE  OF  THE  CHEST.  (Butler.) 


26 


PHYSICAL    DIAGNOSIS 


terminates  with  the  same  anatomic  surface  relations  as  the  greater 
fissure  on  the  right  side — i.  e.,  posteriorly,  third  dorsal  vertebra ;  lat- 
erally (axilla),  fourth  rib;  anteriorly,  sixth  rib. 

Lobes  of  the  Lungs. — The  position  of  the  lobes  is  therefore  as 
follows:  generally  stated,  the  upper  lobes  present  mainly  in  front, 


Fia.  4. — SHOWING  THE  LOBES  OF  THE  LTTNGS  AND  THE  LOWER  LIMIT  OF  THE  PLEURA 
POSTERIORLY.     (Butler.) 

and  the  lower  lobes  behind.  More  specifically:  ANTERIORLY,  on  the 
right  side  we  have  upper  lobe  as  far  down  as  the  fourth  rib;  from 
there  down  to  the  sixth  rib,  the  middle  lobe;  on  the  left  side,  upper 
lobe  practically  alone.  LATERALLY,  at  the  right,  parts  of  the  upper, 
middle,  and  lower  lobes;  on  the  left  side,  portion  of  upper  lobe  (to 
fourth  rib),  and  lower  lobe  downward  to  eighth  rib.  POSTERIORLY, 
on  both  sides,  upper  lobe  (apices)  as  far  as  the  scapular  spines,  below 
which  the  rest  is  lower  lobe. 


In  quiet  respiration  the  borders  of  the  lungs  do  not  coincide  with 
the  limits  of  the  pleural  sacs,  though  their  boundaries  correspond 
most  closely  along  the  anterior  edges  of  the  lungs  down  to  the  fourth 
ribs.  But  along  the  lower  borders  of  the  lungs  and  at  the  cardiac 


PLATE    VIII 


LANDMARKS  AND  LINES  OF  THE  POSTERIOR  SURFACE  OF  THE  CHEST. 


ANATOMY    OF    THE    CHEST  27 

notch  on  the  left  side  below  the  fourth  rib  the  pleural  spaces  extend 
some  distance  beyond  the  former;  here  these  spaces  are  termed  the 
complemental  pleural  sinuses.  With  deep  inspiration  the  lungs  may 
expand  sufficiently  to  fill  the  complemental  pleural  spaces.  Their  size 
depends  upon  the  form  and  development  of  the  lungs  and  thorax. 
The  largest  space  is  below  the  inferior  borders  of  the  lungs  in  the 
infra-axillary  regions,  the  height  being  as  much  as  three  and  one-half 
inches  (10  cm.).  In  the  mammillary  and  scapular  lines  the  distance 
is  from  one  and  one-half  to  two  inches  (4  to  5  cm.). 


ADDITIONAL    ANATOMIC    LANDMARKS 

The  bifurcation  of  the  trachea,  it  should  be  remembered,  is  at 
the  level  of  the  angle  of  Louis,  or  second  costal  cartilage,  and  of  the 
disk  between  the  third  and  fourth  dorsal  vertebra?. 

Primary  Bronchi. — The  right  bronchus  is  larger  in  caliber  than 
the  left,  shorter  in  length,  more  horizontal  in  direction,  and  lies  under 
the  second  rib,  whereas  the  left  lies  under  the  second  interspace.  The 
proximity  of  the  right  bronchus  and  its  main  branch  to  the  upper 
lobe  has  important  bearing  upon  certain  auscultatory  phenomena  over 
this  region,  as  will  be  referred  to  later. 

The  surface  relations  of  the  lungs  to  such  organs  as  the  heart, 
liver,  spleen,  and  stomach,  which  are  partly  covered  by  the  lungs, 
will  be  pointed  out  as  their  relations .  with  each  other  are  developed 
according  to  the  pathologic  conditions  affecting  them. 

Supplemental  to  the  preceding,  it  should  be  noted  that  the  summit 
of  the  diaphragm  is  as  high  as  the  level  of  the  fourth  rib  on  the 
right  side  (about  an  interspace  higher  than  on  the  left),  the  inferior 
surface  of  the  lung  capping  it,  and  extending  outward  and  downward 
to  a  wedge-shaped  edge  at  the  sixth  rib  in  the  mammillary  line,  etc. 


CHAPTER    II 
INSPECTION 

Definition. — Inspection  is  the  act  of  looking  intelligently  and 
attentively,  and  is  naturally  the  first  method  in  examining  a  patient's 
chest,  and  by  it  the  physical  evidences  of  thoracic  disease  are  obtained 
with  more  or  less  clearness,  directness,  and  positiveness.  In  fact, 
the  student  should  avoid  neglecting  or  slighting  this  old  and  simple 
method  because  of  the  attractiveness  of  the  more  modern,  but  more 
difficult  and  involved,  if  precise  and  penetrating,  methods  of  per- 
cussion and  auscultation.  Undue  haste  and  self-confidence  on  the 
part  of  the  examiner,  and  false  modesty  or  a  stubborn  fastidiousness 
on  the  part  of  the  patient  may,  of  course,  tend  to  develop  the  per- 
nicious habit  of  lack  of  thoroughness  in  omitting  a  careful  and  com- 
plete ocular  examination. 

Method  of  Procedure. — No  chest  can  be  inspected  unless  it  be 
exposed.  As  most  of  the  regions  of  the  thorax,  as  well  as  the  appear- 
ances of  the  thorax  in  its  entirety,  must  be  noted  in  any  proper 
examination  of  the  thoracic  organs,  it  is  usually  necessary  to  have 
the  patient  stripped  to  the  waist,  whether  standing,  sitting,  or  lying. 
Of  course,  circumstances  may  frequently  arise  to  modify  this  prin- 
ciple. Thus,  in  examining  females  a  sense  of  propriety,  or  with  the 
very  delicate  and  sensitive  physically,  or  the  very  ill,  a  motive  of 
precaution  will  suggest  the  exposure  of  one  aspect  of  the  chest,  or  its 
greater  portion,  at  one  time.  Again,  after  the  seat  of  disease  has 
been  detected  by  a  thorough  examination,  it  is  often  sufficient  at 
subsequent  meetings  to  limit  the  examinations  to  this  locality. 

A  good,  steady,  white  light  (preferably  daylight)  is  of  first  im- 
portance. The  patient  should  lie,  stand,  or  sit  on  a  perfectly  even 
plane;  the  position  should  be  quite  comfortable,  relaxed  and  easy, 
the  arms  allowed  to  hang  loosely  by  the  side.  The  sitting  or  standing 
postures  should  be  selected  whenever  possible.  As  a  rule,  the  light 
should  fall  directly  and  symmetrically  upon  the  surface  to  be  exam- 
ined, the  examiner  standing  with  back  to  the  light.  A  side  or  slant- 
28 


INSPECTION  29 

ing  light  falling  obliquely  upon  the  surface  examined  by  turning  the 
patient  or  moving  the  source  of  illumination  is  often  advisable,  how- 
ever; abnormal  bulgings  and  depressions,  and  the  moving  shadows 
of  abnormal  pulsations,  are  thus  readily  detected,  whose  diagnostic 
importance  may  be  considerable.  Inspection  should  be  practised  an- 
teriorly, posteriorly,  laterally  (the  arms  being  raised),  and  superiorly; 
the  latter,  by  standing  behind  or  alongside  the  patient,  enables  the 
physician  to  estimate  approximately  the  anteroposterior  diameter  of 
the  chest,  its  outline  on  an  imaginary  horizontal  section,  and  further 
accentuate  any  general  or  circumscribed  abnormalities  of  size,  contour, 
or  movement.  The  patient's  body  and  members  should  be  quiet,  the 
breathing  easy  and  uninterrupted  by  conversation.  Always,  observa- 
tion should  be  comparative;  that  is,  both  sides  habitually  compared 
generally  and  in  respect  to  corresponding  regions.  In  the  compari- 
son, allowances  must  be  made  for  the  obviously  natural  differences, 
as  of  greater  muscular  development  on  one  side,  and  for  certain 
physical  and  accidental  irregularities  that  may  be  peculiar  to  each 
individual  examined. 

We  begin  with  the  visible  characteristics  of  structure  and  move- 
ment of  the  normal  thorax,  in  order  that  the  physical  evidences  of 
thoracic  disease  may  more  surely  be  discriminated. 


THE    NORMAL   THORAX 

The  ability  to  recognize  the  normal  thorax  distinctly  and  readily 
depends  upon  one's  general  observation  and  clinical  experience;  in 
familiarity  with  the  proportions,  forms,  and  movements  of  the  bared 
chests  of  athletes,  swimmers,  laborers,  and  others  of  manifestly  aver- 
age health  and  physical  development,  including  patients  examined 
while  consulting  for  ailments  other  than  thoracic,  or  for  slight  or 
obscure  chest  troubles  without  external  physical  alterations. 

Perfect  symmetry  of  chest  is  rarely  found.  The  regularly  con- 
structed and  well-nourished  chest  of  the  adult  male,  viewed  anteriorly, 
and  exclusive  of  its  shoulder  girdle,  is  conoidal  in  shape,  having  the 
smaller  end  uppermost;  with  the  shoulder  attachments,  however,  the 
chest  appears  larger  at  the  level  of  the  axilla  than  at  the  ensiform 
cartilage ;  the  two  sides  are  both  generally  and  regionally  symmetrical ; 
the  clavicles  are  slightly  prominent,  and  the  supra-  and  infraclavicular 
depressions  slightly  noticeable;  there  are  small  depressions,  one  above 
the  suprasternal  notch  between  the  inner  ends  of  the  clavicles  and  one 


30  PHYSICAL    DIAGNOSIS 

(infrasternal)  over  the  xiphoid  process;  the  intercostal  spaces  are 
visible  only  at  the  lower  and  lateral  ribs;  the  sternum  in  profile  is 
nearly  straight;  the  angle  of  Louis  (formed  by  the  union  of  the 
manubrium  and  gladiolus  of  the  sternum)  is  slightly  but  distinctly 
marked  at  the  landmark  level  of  the  junction  of  the  second  rib;  the 
sternovertebral  (anteroposterior)  diameter  is  obviously  a  little  shorter 
than  the  transverse  (about  one-fourth  less:  see  Mensuration),  the 
shape  of  a  transverse  section  being  elliptoid;  the  ribs  so  leave  the 
sternum  that  from  above  downward  their  course  changes  gradually 
from  the  horizontal  to  a  decided  obliquity,  the  coalesced  costal  car- 
tilages of  both  sides  forming  at  the  xiphoid  nearly  a  right  angle 
(epigastric  or  subcostal  angle) ;  posteriorly,  the  scapulae  lie  flat  upon 
the  thorax,  in  the  upright  position,  and  are  so  highly  placed  that  the 
shoulders  stand  out  nearly  horizontal  from  the  neck;  the  spine  is 
straight  or  but  very  slightly  curved  to  the  right  at  mid-back,  and  the 
vertebral  sulcus  more  or  less  deep,  according  to  the  fatness  or  thin- 
ness of  the  individual. 

Although  this  ideal  form  of  thorax  is  seldom  met  with,  the  devia- 
tions about  to  be  mentioned  commonly  occur  in  persons  of  sound 
general  health  and  thoracic  organs.  These  compatible  irregularities, 
or  "physiological  heteromorphisms  " — departures  (M.  Woillez) — are 
principally  as  follows:  (congenital)  a  form  of  thorax  with  shallow 
upper  but  gradually  wider  and  deeper  lower  zone;  a  shorter  thorax 
with,  at  the  same  time,  acute  epigastric  angle;  marked  prominence 
of  the  clavicles,  with  deepened  supraclavicular  spaces  on  both  sides 
(relative);  marked  angle  of  Louis;  greater  prominence  of  one  or 
several  ribs,  especially  the  second,  third,  and  fourth,  in  front,  with 
increased  curvature,  or  the  lower  ribs  may  be  pressed  in  and  flattened ; 
finally,  we  sometimes  find  the  ensiform  cartilage  projecting  decidedly 
forward  or  backward;  (acquired)  the  right  side  may  be  larger  than 
the  left,  owing  to  greater  muscular  development,  as  in  brakemen, 
blacksmiths,  and  carpenters;  one  shoulder  may  be  a  little  lower  than 
the  other,  and  the  dorsal  spine  curved  slightly,  usually  to  the  right, 
as  in  journalists,  litterateurs,  clerks,  tailors,  hod-carriers,  and  the 
like.  Again,  there  may  be  slight  differences  in  the  relations  between 
the  natural  diameters  of  the  chest.  Partial  or  local  defects  of  sym- 
metry are  also  discovered  due  to  previous  fractures  and  dislocations 
of  clavicles  and  ribs,  and  all  may  be  compatible  with  perfectly  normal 
lungs  and  heart. 

Normal  Chest  Movements. — Whether  purposely  forced,  or  involun- 
tary and  quiet,  the  normal  breathing  movements  are  regular,  rhyth- 


INSPECTION  31 

mical,  gradual,  and  symmetrical — quite  equal  and  even  on  both  sides. 
Observation  of  these  general  thoracic  movements  has  direct  reference 
to  the  inspiratory  and  expiratory  functions  of  the  lungs,  the  former 
characterized  by  a  simultaneous  expansion  and  elevation  of  the  thorax 
and  the  latter  by  a  simultaneous  retraction  and  depression ;  the  former 
active — that  is,  produced  by  diaphragmatic  and  intercostal  muscular 
action  principally;  the  latter  passive,  the  result  of  the  elasticity  of 
the  lungs,  the  weight  of  the  chest  wall,  and  the  resilient  pressure 
of  the  abdominal  organs  against  the  diaphragm. 

By  inspection  we  learn,  then,  the  size,  shape,  and  symmetry  of 
the  chest ;  the  rate  or  frequency  of  respiration  (more  often  an  objective 
symptom),  and  the  rhythm,  degree,  and  character  of  the  breathing 
movements  as  physical  signs. 

TYPES  OF  NORMAL  EESPIRATORY  MOVEMENT. — Before  describing 
the  preceding  features,  it  should  be  borne  in  mind  that  there  are  in 
health  two  types  of  respiration,  named  according  to  the  predominance 
of  either  one  of  the  two  larger  elements  seen  in  all  normal  respiratory 
action.  These  are  (1)  the  superior  thoracic  or  costal  type  and  (2) 
the  abdominal,  diaphragmatic,  or  inferior  costal  type.  Abdominal 
respiration  is  more  marked  in  men  and  in  children  of  both  sexes; 
superior  costal  respiration  in  women.  In  the  costal  type  of  breathing, 
the  upper  anterior  part  of  the  thorax  swells  out  more  fully  with  each 
inspiratory  enlargement;  the  lower  costal  and  ventral  movements  are 
comparatively  limited.  The  costo-abdominal  or  diaphragmatic  type 
of  breathing — the  ordinary,  calm  breathing  of  adult  males — predom- 
inating, we  notice  the  characteristic  swelling  projection  of  the  abdo- 
men, especially  the  epigastrium,  simultaneous  with  the  general  expan- 
sion of  the  chest,  and  thus  produced  by  the  contraction  and  flattening 
of  the  diaphragm  pushing  the  intestines  against  the  belly  wall.  The 
preponderance  of  either  type  of  breathing  is  modified  somewhat  by 
the  following  influences:  Age,  determining  the  degree  of  flexibility 
of  the  bony  case,  permits  in  early  youth,  for  example,  greater  relative 
freedom  of  pectoral  movement  in  the  male,  also  more  general  action 
and  less  limitation  to  the  upper  regions  of  the  thorax  in  the  female; 
however,  the  marked  evidences  of  the  superior  costal  type  of  respira- 
tion, even  in  very  young  girls,  Show  (as  do  those  of  the  abdominal 
type  in  boys)  the  fundamental  sexual  differences  of  heredity.  Again, 
in  aged  women,  with  firm  and  more  or  less  unyielding  thoracic  walls, 
the  abdominal  movements  are  increased.  During  sleep  the  costal 
breathing  is  more  pronounced  in  men  as  well  as  in  women;  this  ob- 
servation is  true  also  when  voluntary  forced  breathing  is  practised, 


32 


as  in  singing;  indeed,  there  may  be  habitual  exaggeration  to  a  slight 
degree  of  the  upper  costal  action  in  professional  singers  even  during 
quiet  breathing.  There  is  no  doubt  that  the  custom  of  wearing  tightly 
laced  and  rigid  corsets  is  partly  responsible  for  the  excess  of  upper 
chest  movement  seen  in  most  women. 

In  regard  to  the  thoracic  breathing,  it  should  be  noted  that  the 
diverging  movement  of  expansion,  with  increase  of  the  horizontal 
diameters,  is  visibly  more  decided  than  that  of  elevation  of  the  ribs, 
but  that  the  energy  and  extent  of  both  are  directly  proportionate 
to  each  other  under  all  circumstances  of  health.  The  movements  of 
the  intercostal  spaces  are  distinguishable  according  to  the  thinness 
of  the  individual,  the  regions  observed,  and  the  force  of  the  breathing. 
In  the  male,  the  interspaces  are  most  visible  in  the  infra-axillary 
regions;  in  the  female,  in  the  infraclavicular  regions.  They  are 
slightly  hollow  both  during  inspiration  and  expiration,  though  more 
so  during  the  former,  and,  naturally,  markedly  so  in  forced  breathing. 
Finally,  the  respiratory  movements  may  be  altered  in  the  normal 
chest  by  posture.  Thus,  when  lying  on  one  side,  in  calm  breathing, 
the  motion  of  that  side  is  interfered  with,  resulting  in  compensatory 
exaggerated  movement  on  the  opposite  side.  The  fact  that  either 
the  costal  or  diaphragmatic  type  of  respiration  may  be  exaggerated 
in  certain  diseases  makes  it  important  to  recognize  these  types  and 
their  conditional  variations  in  health  in  order  that  the  pathological 
may  be  estimated  better. 

THE  DIAPHRAGMATIC  PHENOMENON  (Litten's  Sign). — Inspection 
of  this  moving  indicator  of  the  action  of  the  diaphragm  requires 

special  consideration  because 
of  its  diagnostic  value.  The 
sign  itself,  as  well  as  the 
method  of  observing  it,  will 
be  understood  by  a  brief  and 
diagrammatic  reference  to 
the  anatomy  and  physiology 
of  the  diaphragm.  The  ac- 
companying diagram  (from 
Cabot)  will  aid  in  under- 
standing the  mechanism  of 
the  production  of  this  phe- 
nomenon—a moving  shadow.  As  at  the  end  of  expiration  the  diaphragm) 
I  lies  in  close  apposition  to  the  walls  of  the  thorax  from  the  sixth  rib  down! 
to  its  attachment,  during  inspiration  it  descends,  and,  separating  f  romf 


FIG.  5. — DIAGRAM  ILLUSTRATING  THE  MECH- 
ANISM OF  THE  DIAPHRAGMATIC  PHENOME- 
NON. (Cabot.) 


INSPECTION  33 

[the  ribs,  leaves  room  for  the  lung  to  descend  also.  This  "  peeling  off  " 
iof  the  diaphragm  causes  a  shadowy,  wavelike  retraction  of  the  inter- 
costal spaces  of  the  lower  lateral  aspects  of  the  chest,  due  probably 
to  the  external  pressure  exceeding  the  intrapulmonary  at  the  begin- 
ning of  inspiration,  the  balance  of  pressure  being  restored  as  soon  as 
expansion  of  the  lung  is  completed.  Although  present  in  all  healthy 
individuals,  it  is  best  seen  in  those  who  are  thin  and  muscular.  The 
phenomenon  is  best  observed  in  the  following  manner:  the  patient 
lies  flat  on  his  back,  with  bared  chest,  and  face  looking  directly  toward 
a  window  or  strong  night  light,  the  head  being  slightly  elevated; 
side  lights  should  be  carefully  excluded.  The  observer  stands  at  a 
distance  of  a  few  feet  from  the  patient's  side,  with  back  to  the  light, 
and  views  at  an  angle  while  the  patient  takes  a  full,  deep  breath. 
With  the  beginning  of  inspiration  a  small,  narrow,  wavy  shadow  is 
seen  to  move  down  the  axilla  (on  either  side)  from  the  sixth  rib  or 
seventh  interspace  to  the  ninth  or  tenth  ribs,  or  even  to  the  borders 
of  the  ribs.  The  movement  of  the  shadow  in  normal  chests  is  about 
two  and  one-half  inches;  with  strongest  breathing,  about  one  inch 
more.  The  rising  movement  of  the  shadow  during  expiration  is  less 
distinctly  visible  than  the  falling,  inspiratory  one.  I  have  observed 
this  phenomenon  in  the  epigastrium  in  several  instances.  As  will  be 
pointed  out  later,  the  absence  of  this  sign  is  suggestive  of  certain 
affections  of  the  lungs  and  pleura  that  interfere  with  the  action  of 
the  diaphragm. 

It  may  also  serve  as  an  index  of  a  person's  respiratory  capacity, 
according  to  the  measured  excursion  of  movement  as  compared  with 
the  general  chest  effort;  thus,  as  intimated  by  Cabot,  the  use  of  the 
spirometer,  as  well  as  of  the  X-rays,  in  observing  the  diaphragmatic 
movements  may  be  compensated  for  whenever  their  impracticability 
or  expensiveness  are  obstacles,  or,  as  often  happens,  when  they  are 
practically  unnecessary. 

FREQUENCY  OF  KESPIRATORY  MOVEMENTS. — Though  not  strictly 
a  physical  sign  in  itself,  the  rapidity  of  breathing  is  so  closely  related 
to  pathologic  conditions  of  the  thorax  of  marked  physical  character- 
istics that  the  normal  rate  and  its  physiologic  variations  must  first 
lie  noted.  In  healthy  adult  males  the  respiration  rate  is  from  16  to  22 
per  minute;  in  females  it  may  be  from  18  to  24;  in  children  of  five 
years,  about  2G;  in  the  new-born  and  under  one  year,  about  44.  Be- 
sides age,  the  rapidity  of  the  respirations  may  be  influenced  by  other 
intrinsic  and  certain  external  conditions :  it  is  greater  in  walking, 
standing,  and  sitting  than  in  lying;  it  is  increased  after  meals,  and 


34  PHYSICAL    DIAGNOSIS 

with  bodily  exercise,  mental  activity,  and  emotional  excitement.  It 
is  likewise  more  marked  in  spring  than  in  midsummer,  except  when 
excessive  heat  acts  upon  the  temperature  of  the  body ;  during  the  day 
than  at  night,  and  in  the  rarefied  atmosphere  of  elevated  regions  than 
in  the  lowlands.  As  the  frequency  of  the  respirations  may  be  altered 
subconsciously  in  persons  who  are  temperamentally  sensitive  while 
under  observation,  it  is  my  custom  to  count  the  breathings  before 
relinquishing  attention  to  the  pulse-rate  or  to  the  timing  of  the  ther- 
mometer. Of  course,  during  sleep  a  more  correct  estimate  may  be 
obtained  in  many  cases.  The  epigastric  as  well  as  the  thoracic  rise 
and  fall  may  be  watched  in  counting  the  respirations,  and  aided 
often  by  applying  the  hand  or  by  noting  the  breath  sounds. 

NORMAL  RESPIRATORY  RHYTHM. — The  relative  duration  of  in- 
spiration to  expiration  in  quiet  breathing  is  visibly  about  equal; 
physiologically  and  more  precisely,  however,  the  ratio  is  about  as 
6  to  7.  Inspiration  begins  suddenly  and  advances  rapidly,  then 
slackens;  expiration  follows  so  closely  that  no  distinct  pause  is  per- 
ceptible between  it  and  inspiration;  expiration  begins  rapidly,  and 
slows  gradually  to  the  close.  The  pause  at  the  end  of  expiration 
is  more  observable  the  slower  the  respiration.  The  regularity 
of  the  successive  respirations  may  be  varied  normally  in  forced 
and  hurried  breathing,  in  which  the  inspiration  becomes  relatively 
shorter  in  duration.  In  children  the  rhythm  is  also  very  variable, 
whether  asleep  or  awake.  Pathologic  alterations  of  rhythm  are 
usually  associated  with  the  physical  evidences  of  labored  breathing, 
or  dyspnea. 

The  DEGREE  OF  NORMAL  RESPIRATORY  EXPANSION  is  more  precisely 
determined  by  mensuration  than  by  either  inspection  or  palpation. 
It  is  affected  in  general  by  the  degree  of  pulmonary  development 
and  exercise,  and  must  be  equal  on  both  sides. 

Nutrition. — The  chest  in  health  shows  a  sufficient  amount  of  flesh 
and  subcutaneous  fat  so  that  the  clavicles,  ribs,  and  scapulae  are  nicely 
covered  and  not  too  prominent;  nor,  on  the  other  hand,  that  the 
shallow  depressions  do  not  sink  in  too  much.  Emaciation  is  closely 
related  to  various  affections  of  the  lungs  and  pleurae. 

MENSURATION 

(Thoracometry ,  Cyrtometry,  Spirometry,  etc.) 

It  seems  to  me  a  mistake  to  subordinate  the  relative  importance 
of  thoracic  measurements,  as  is  so  commonly  done.  With  the  growing 


INSPECTION  35 

adoption  of  diagnostic  methods  of  precision,  this  most  precise  one — 
mensuration — deserves  at  once  increasing  scientific  study  and  prac- 
tical application.  As  a  method  of  physical  examination  it  has  special 
value  to  those  physicians — and  they  are  becoming  numerous — who 
perform  the  responsible  and  exacting  duties  of  medical  examiners 
for  life-insurance  companies,  pension  boards,  railroad  corporations, 
and  the  like,  or  who  serve  as  physical  directors  to  the  various  edu- 
cational and  philanthropic  institutions  (Y.  M.  C.  A.'s)  conducting 
well-equipped  and  modernly-managed  gymnasiums. 

As  the  results  obtained  by  inspection  are  so  intimately  related  to — 
being  confirmed  or  modified  by — those  derived  by  mensuration,  the 
latter  requires  consideration  at  this  point. 

The  object  of  measuring  the  chest  is  to  ascertain  more  accurately 
than  can  be  done  by  inspection  or  palpation  the  general  size  or  bulk 
and  shape,  the  comparative  size  and  shape  or  symmetry  of  the  two 
sides,  the  relative  positions  of  different  parts  and  their  distances  from 
fixed  points,  with  the  thorax  at  rest,  and  to  determine  the  degree 
and  variations  in  the  bilateral,  unilateral,  or  local  expansion  and 
retraction  accompanying  the  movements  of  inspiration  and  ex- 
piration. 

Ordinarily,  the  circumference  and  semicircumference  of  the  chest 
are  measured  with  the  tape,  and  the  principal  diameters  with  the 
thoracometer  or  calipers  (such  as  obstetricians  use  for  pelvic  measure- 
ments). 

Thoracometry. — The  circumference  is  the  main  measurement, 
taken  usually  at  the  level  of  the  nipples  in  men,  or  a  little  above, 
at  the  third  costosternal  articulation,  just  at  the  upper  edge  of  the 
mammae,  especially  important  in  women.  Care  should  be  taken  that 
corsets  and  all  chest  coverings  except  a  light,  loose  undergarment 
are  removed,  the  body  in  a  resting,  easy,  upright  position,  and  that 
the  tape  is  horizontally  and  evenly  applied  around  the  thorax.  In 
this  way  the  general  size  and  degree  of  expansion  of  the  chest  are 
ascertained. 

The  average  circumference  in  men  (repose)  is  about  34.3  in. ;  in 
women,  30  in.  There  are  many  variations,  of  course,  in  healthy 
individuals  from  these  approximate  measurements,  depending  upon 
age,  height,  weight,  or  the  relation  to  the  development  of  the  rest 
of  the  body.  The  extremes  are  usually  between  27  and  44  in. 


36 


PHYSICAL    DIAGNOSIS 


Table  showing  Size  of  Chest  in  Relation  to  Height  and  Weight. 


Height. 

Chest. 

Weight 

(Standard). 

Twenty  per  cent 
under  weight. 

Forty-five  per  cent 
over  weight. 

5ft. 

33    in. 

115  Ibs. 

92    Ibs. 

167    Ibs. 

5 

1  in. 

34 

120    " 

96 

' 

174      " 

5 

2 

35 

125     " 

100 

' 

1814    " 

5 

3 

36 

130    " 

104 

' 

188*     ' 

5 

4 

364 

135    " 

108 

' 

195       ' 

5 

5 

37 

140    " 

112 

' 

203       ' 

5 

6 

37* 

143    " 

114 

' 

207      ' 

5 

7 

38 

145    " 

116 

1 

210       ' 

5 

8 

384 

148    " 

119* 

c 

215      " 

5 

9 

39 

155     " 

124 

1 

2244    " 

5 

10 

394 

160     ' 

128 

' 

232      " 

5 

11 

404 

165     ' 

132 

' 

239      " 

6 

41 

170     ' 

136 

246      " 

6 

1 

414 

175     ' 

140 

' 

253      " 

6 

2 

424 

180     ' 

144 

' 

260      " 

Respiratory  Expansion. — This  important  measurement  is  also 
taken  with  the  tape,  and  represents  the  difference  between  the  cir- 
cumference at  the  end  of  a  forced  inspiration  and  of  a  forced  expira- 
tion. During  calm  respiration  the  circumferential  expansion  is  very 
slight — hardly  more  than  one-half  of  an  inch  in  a  well-developed  male 
adult.  The  extremes  of  expansion  vary  normally  from  2  to  5  in. ; 
the  average  in  men  is  about  3  in.;  in  women,  2^  in.  An  applicant 
for  life-insurance  with  an  expansion  of  less  than  2  in.  is  likely  to 
be  rejected  as  an  unfavorable  risk.  It  should  be  borne  in  mind  that 
many  persons  with  healthy  chests  are  often  unable  to  produce  their 
fullest  expansion  owing  to  embarrassment  or  lack  of  coordinating 
power;  on  the  other  hand,  some  less  robust  persons  who  are  practised 
in  deep  breathing  or  in  accessory  muscular  action  may  easily  expand 
4  or  4^  in.,  while  certain  phenomenal  athletes  may  develop  as  much 
as  7  in.  of  expansion.  The  amount  of  expansion  is  influenced  by 
posture,  being  least  in  recumbency,  more  in  sitting,  most  of  all  in 
the  erect,  standing  position.  Forced  breathing  has  no  more  effect 
upon  the  abdominal  expansion  than  is  mensurable  around  the  thorax 
during  ordinary  quiet  respiration — that  is,  about  i  to  |  in. 

Semicircumference. — This  may  be  obtained  accurately  for  both 
sides  by  the  use  of  two  tapes  joined  at  the  commencement  of  their 
scales,  and  padded  slightly  a  little  beyond  the  point  of  junction  so  as 
to  rest  like  a  saddle  piece  over  the  spine.  The  measurements  are 
taken  simply  by  passing  each  tape  around  its  respective  half  of  the 
chest  to  the  midsternal  line  and  reading  off  the  separate  inches  or 


INSPECTION 


37 


centimeters,  as  may  be  marked.  The  right  half  measures  normally 
(at  the  nipples)  from  5  to  |  in.  more  than  the  left  in  right-handed 
persons;  in  left-handed  persons  the  left  semicircumference  may  equal 
or  slightly  exceed  the  right  (^  in.). 

The  UNILATERAL  EXPANSION  of  the  chest  may  be  measured  also 
by  noting  the  differences  on  the  scales  for  each  side  with  complete 
expiration  and  inspiration. 

The  DIAMETERS  of  the  chest  may  be  measured  by  means  of  the 
thoracometer  or  caliper  compasses.  The  anteroposterior  or  sttrno- 
vertebral  diameter  is  taken  by  applying  one  blade  of  the  calipers  on 
a  level  with  the  nipple,  in 
the  midsternal  line,  and 
the  other  at  the  insertion 
of  the  second  rib  behind. 
The  transverse  diameter  is 
measured  at  the  highest 
point  of  the  axilla?,  and  in 
the  normal  chest  is  a  little 
greater  than  the  antero- 
posterior. The  average 
depth  of  the- chest  is  about 
7^  in.  in  men,  about  7  in. 
in  women;  the  breadth 
averages  about  10  in.  in 
men. 

The  LENGTH  of  the 
thorax  may  be  ascertained 
by  measuring  from  the 
clavicle  to  the  lowest  bor- 
der of  the  ribs,  along  the  midclavicular  line.  As  a  basis  for  esti- 
mating chest  length  and  variations  therefrom,  the  linea  costo-articu- 
laris  (line  drawn  from  the  sternoclavicular  articulation  to  the  tip  of 
the  eleventh  rib)  may  be  used  also. 

Cyrtometry. — This  determines  the  shape  of  the  chest  by  several 
means  of  outlining,  usually  on  a  level  with  the  nipples,  though  it 
may  be  desirable  sometimes  to  represent  a  transverse  section  of  the 
chest  at  any  higher  or  lower  plane. 

The  cyrtometer  of  Woillez,  often  referred  to  by  authors,  is  of 
historical  rather  than  practical  interest.  It  consists  of  a  chain  of 
stiffly  moving  links,  which  may  be  closely  applied  to  the  circumfer- 
ence of  the  chest  and  carefully  removed  so  as  to  preserve  its  outline 


38 


PHYSICAL    DIAGNOSIS 


when  placed  on  a  table,  and  its  characteristics  and  diameters  noted. 
A  simple  and  sufficient  instrument  for  ordinary  clinical  purposes 
consists  of  two  narrow,  tapelike,  leaden  strips  joined  by  a  stout  leather 
hinge,  or  with  very  short  flexible  attachments,  to  a  padded  metal 
vertebral  piece.  The  latter  being  held  firmly  over  the  spine  at  the 
desired  level,  the  strips  are  molded  accurately  around  the  chest  and 
pencil-marked  where  they  cross  anteriorly,  in  the  middle  line.  After 
carefully  removing  the  pieces  so  as  to  hold  their  shape,  the  contour 
may  be  delineated  on  a  sheet  of  paper  by  laying  them  thereon,  being 
sure  that  the  sternal  ends  are  crossed  as  marked ;  the  outline  may  then 
be  traced  inside  the  borders  of  the  strips.  The  form  of  the  cross- 
section  of  the  chest  may  be  traced  around  the  diameters  obtained 
previously  with  the  calipers  and  marked  on  the  paper,  thus  com- 
pleting the  mensuration. 

CHEST  PANTOGRAPH. — This  new  instrument  for  recording  chest 
contours  was  contrived  by  Dr.  W.  S.  Hall,  of  Northwestern  University, 


FIG.  7. — HALL'S  CHEST  PANTOGRAPH. 


Illinois.  It  is  a  modification  of  the  pantograph  used  by  artists  for 
the  purpose  of  enlarging  figures  from  smaller  copies,  whereas  this 
reverses  the  process.  The  instrument  is  made  of  wood  or  brass,  with 
a  brass  or  steel  semicircle. 

Hall  describes  the  method  of  working  as  follows :  "  The  joints 
a,  6,  x,  and  y  move  easily  in  the  plane  of  the  instrument.  The 
semicircle,  40  in.  in  diameter,  rotates  at  x  around  the  diameter  tx. 
The  point  f  is  fixed  to  a  table.  With  f  a  fixed  point,  all  movements 
of  t,  the  tracing  point,  are  accompanied  by  corresponding  movements 
of  r,  the  recording  point.  The  triangles  /,  r,  I  and  f,  t,  a  are  similar 


INSPECTION 


39 


triangles  in  all  positions  of  the  instrument ;  fb:fa:ifr:ft;  but 
/& :/'«::  1 :  5 ;  therefore,  the  distance  fr  is  always  one-fif th  the  dis- 
tance ft. 

"  The  object  of  the  semicircular  arm  is,  of  course,  to  permit  the 
tracing  point  (t)  to  be  carried  around  the  thorax.  The  seat  upon 
which  the  subject  sits  is  adjustable  in  height,  and  has  back  and  side 
supports  for  the  waist,  so  that  the  upper  part  of  the  body  is  not 
allowed  to  waver  from 
side  to  side,  distorting 
the  contour.  If  the  sub- 
ject to  be  examined  sit 
beside  the  table  on  which 
the  instrument  is  fixed, 
if  the  seat  be  adjusted  in 
height  to  bring  the  plane 
of  the  thorax  to  be  ex- 
amined into  the  plane  of 
the  instrument — i.  e.,  on 
a  level  with  the  top  of 
the  table;  if  a  sheet  of 
millimeter  paper  be  fixed 
to  the  table  under  the 
recording  pencil  r,  and 
if  the  tracing  point  t  be 
swept  around  the  tho- 
racic wall,  a  record  of 
the  chest  contour  will  be 
traced  upon  the  paper." 

Three  pantograms 
represent  outlines  taken 
at  the  axillary,  nipple, 
and  abdominal  planes  re- 
spectively. 

Additional  points  of 
value  that  may  be  stud- 
ied  are  the  relative  in- 
crease in  the  anteropos- 
terior  and  lateral  diam- 
eters in  forced  inspiration,  the  differences  between  the  cross-sectional 
areas  (in  centimeter  squares)  of  expiration  and  inspiration,  and  local 
prominences  of  musculature,  bony  irregularity,  or  pathological  altera- 


FIG.  8. — CHEST  PANTOGRAMS,  TAKEN  AT  THREE 
PLANES.  (W.  S.  Hall.) 


40  PHYSICAL    DIAGNOSIS 

tion  of  contour.  These  graphic  records  of  chest  contour,  reduced  in 
size,  are  well  adapted  for  filing  with  the  general  notes  of  a  case,  and 
pantograms  taken  at  successive  intervals  lend  themselves  readily  to 
a  more  accurate  knowledge  of  thoracic  changes. 

It  has  been  demonstrated  quite  recently  by  Malone  (Journal  Am. 
Med.  Assn.,  September  17,  1904),  in  a  diametric,  pantographic,  and 
mathematic  study  of  a  large  number  of  chests,  that  broad  chests 
have  a  greater  cross-sectional  area,  both  for  inspiration  and  expira- 
tion, than  deep  chests;  also  a  greater  area  expansion  and  a  greater 
capacity  (volume  expansion)  than  do  deep  chests. 

Spirometry. — The  employment  of  Hutchinson's  spirometer  gives 
us  an  idea  of  the  absolute  amount  of  air  which  circulates  in  the 
lungs  between  the  extremes  of  deepest  respiration — the  total  breathing 
volume ;  while  circular  mensuration  of  respiratory  movements  indi- 
cate only  relative  amounts  in  different  individuals.  Thus,  with  this 
instrument,  which  is  constructed  on  the  principle  of  a  gasometer,  we 
ascertain  one's  vital  capacity — i.  e.,  the  quantity  of  air  which  can  be 
expelled  with  the  deepest  expiration  after  the  deepest  possible  inspira- 
tion. The  vital  capacity  is  diminished  in  all  pulmonary  diseases, 
although  there  are  no  diagnostic  or  characteristic  differences  in  the 
vital  capacity  among  these  various  diseases. 

The  physical  conditions  which  influence  the  vital  capacity  are  very 
numerous  and  complex,  even  in  health.  Perhaps  weight  and  stature 
bear  the  most  constant  relation  to  the  vital  capacity,  especially  stature, 
although  there  may  be  a  wide  interval  between  extremes  in  healthy 
persons.  According  to  Otis,  the  average  lung  capacity  for  each  inch 
of  height  is  3.52  cu.  in.  For  a  height  of  67  to  68  in.  inclusive,  the 
lung  capacity  is  about  237  cu.  in. ;  for  a  height  of  69  to  70  in.,  about 
259  cu.  in. ;  for  women  of  about  nineteen  or  twenty  years  of  age, 
with  a  height  of  62  to  63  in.,  the  capacity  of  the  lungs  aver- 
ages from  145  to  150  cu.  in.  In  children  and  in  the  aged  it 
diminishes. 

Von  Ziemssen  and  Klemperer  assert  that  the  normal  ratio  is  about 
22  c.c.  for  each  centimeter  of  bodily  length;  and  that  if  the  ratio 
of  height  to  capacity  was  less  than  1  to  20,  or,  in  women,  less  than 
1  to  17,  there  was  probably  marked  respiratory  disturbance. 

COMPLEMENTARY  AIR,  that  which  may  be  inhaled  by  a  forced, 
after  an  ordinary  quiet,  inspiration,  averages  about  1,500  c.c. 

KESERVE  or  SUPPLEMENTAL  AIR,  or  that  which  may  be  ex- 
haled by  the  deepest,  after  ordinary,  expiration,  also  equals  about 
1,500  c.c. 


INSPECTION  41 

TIDAL  or  BREATHING  AIR,  that  which  is  changed  by  each  calm 
respiration,  amounts  to  about  500  c.c. 

Pneumatometry  determines  the  inspiratory  and  expiratory  pressure 
of  air.  The  pneumatometer  as  devised  by  Waldenburg  is  a  modified 
mercurial  manometer.  It  is  found  in  health  that  the  expiratory 
pressure  is  always  greater  than  the  inspiratory,  exceeding  it  by  about 
20  to  30  mm.  The  results  are  more  variable  than  those  obtained 
by  spirometry. 

Stethography,  or  the  instrumental  tracing  of  the  movements  of 
the  chest  walls  (Ransome),  and  pneumography,  also  -the  recording 
of  such  movements  (Marey),  are  of  much  greater  service  in  physi- 
ological than  in  clinical  research. 


THE    PATHOLOGIC    THORAX 

In  the  inspection  and  mensuration  of  the  thorax  as  a  whole,  and 
independent  of  its  movements,  the  observation  of  three  features  re- 
quires first  consideration — viz.,  size,  shape,  and  symmetry.  A  method- 
ical habit  of  noting  these  may  readily  be  acquired  by  remembering 
the  alliterative  s. 

(1)    SIZE 

As  indicated  previously,  the  visible  and  mensurable  dimensions 
of  the  chest  vary  considerably  in  different  persons  enjoying  good 
health.  Pathologic  disproportions  in  size  may  be  general,  unilateral, 
or  local.  As  one-sided  and  circumscribed  deviations  are  obviously 
asymmetries,  they  are  described  as  such  under  the  third  head.  Of 
course,  abnormal  sizes  of  chest  are  always  more  precisely  estimated 
by  mensuration  than  by  inspection  alone. 

Pathologic  Enlargement. — Abnormal  increase  in  the  size  of  the 
thorax  as  a  whole  may  indicate  predisposition  to  pulmonary  disease, 
or  an  incipient  as  well  as  fully  developed  gross  morbid  condition. 
This  is  frequently  observed  in  those  whose  occupation  necessitates  a 
certain  amount  of  habitual  strain  upon  the  air  vesicles,  as  in  glass- 
blowers,  wind-instrument  players,  etc.  Mountaineers  and  others  liv- 
ing constantly  in  very  high  altitudes,  and  asthmatics,  may  show  slight 
or  moderate  enlargements  even  when  the  other  physical  signs  of  true 
emphysema  may  be  wanting.  The  latter  condition  (permanent  dila- 
tion of  the  vesicles  of  the  lungs)  is,  however,  the  chief  affection  in 
cases  of  marked  increase  in  all  of  the  diameters,  especially  when  most 


42 


PHYSICAL    DIAGNOSIS 


prominently  involving  the  upper  half  of   the  chest.      Both   vertical 
measurements  are  at  the  same  time  usually  shorter  than  normal. 

Pathologic  Smallness. — This  is  particularly  noticeahle  in  persons 
predisposed  to  or  actually  having  tuherculosis;  in  those  who,  in  child- 
hood, were  considered  "  delicate  "  or  "  scrofulous,"  or  mouth-breathers 
because  of  adenoid  growths  in  the  nasopharyngeal  vault,  or,  as  in- 
fants, were  victims  of  marasmus,  rickets,  and  other  wasting  diseases. 
Small  chests  are  also  seen  in  patients  who  have  suffered  long  from 
prostrating  and  more  or  less  malignant  illnesses. 


(2)  SHAPE 

We  learn  the  shape  of  the  thorax  by  intelligent  observation  in 
general,  by  practise  in  the  estimation  of  the  relative  lengths  of  the 

anteroposterior  and  transverse 
diameters,  and  more  precisely  by 
measurements  with  the  thora- 
cometer  and  tracings  with  the 
cyrtometer  and  pantograph. 

There  are  certain  bilateral 
or  symmetrical  abnormalities  of 
shape  so  well  marked  as  to  con- 
stitute distinct  types  of  patho- 
logic chest.  They  may  origi- 
nate from  congenital,  develop- 
mental, or  previous  pathologic 
conditions. 

Paralytic  or  Phthisinoid  Chest. — It  is  abnormally  long,  narrow, 
and  shallow;  the  shoulders  slope  and  droop  downward  and  forward: 
the  neck  is  long  and  the  larynx  and  angle  of  Louis  prominent;  the 
ribs  are  slender,  and  slanting  sharply  downward  from  the  sternum, 
then  also  with  marked  obliquity  backward  to  the  vertebra  form  an 
acute  epigastric  angle;  the  supra-  and  infraclavicular  fossae  and  the 
intercostal  spaces  are  quite  depressed,  and  the  latter  often  widened. 
Owing  to  the  weakness  of  the  shoulder-girdle  muscles,  the  serratus 
anticus  in  particular  ("paralytic"  thorax),  the  vertebral  borders  of 
the  scapulae  project  so  that  the  interscapular  region  may  be  relatively 
deepened  to  the  thickness  of  an  applied  hand,  the  scapulae  thus  stand- 
ing out  winglike,  and  hence  the  designation  alar  or  pterygoid  chest 
sometimes  used. 

This  type  of  thorax  is  seen  in  delicate  children  and  adolescents, 


FIG.  9. — THE  NORMAL  THORAX;  OUTLINE 
OF  TRANSVERSE  SECTION. 


INSPECTION 


43 


predisposed  to  or  in  the  incipiency  of  tuberculosis,  although  it  is  not 
rarelv  found  in  those-  whose  lungs  have  escaped  infection.     It  indi- 


^PPP£' 


FIG    jo. AxTF.Knm  AM>  I'OSTKKK  >u  ASI-KCTS  OF  THE  PHTHISINOID  CHEST.     (Sahli.) 

cates  (••oiigciiitally  small  and  weak  pulmonary  capacity.  The  super- 
vention of  tuberculosis  causes  increase  in  the  flattening  of  the  sterno- 
vertebral  diameter. 

Flat  Phthisical  Chest.— The 
physical  characteristics  are  not 
much  unlike  those  of  an  emaci- 
ated chest  of  normal  proportions 
except  that  the  upper  anterior 
aspect  shows  decided  flattening 
and  consequent  relative  shorten- 
ing of  the  anteroposterior  diam- 
eter. It  points  to  acquired  tu- 
berculosis in  spite  of  the  absence 
of  the  inherited  susceptibility 
usually  associated  with  the  pre- 
ceding type  of  chest.  Furthermore,  as  Woods  Hutchinson  has 
mentioned,  pulmonary  phthisis  may  be  met  with  in  chests  with 


FIG.   11. — THE  FLAT  PHTHISICAL  CHEST. 
(Gee.) 


44 

relatively   normal    or   even   slightly   exaggerated   anteroposterior   di- 
ameters. 

Emphysematous  or  Inflated  Chest. — This  is  quite  the  opposite  of 
the  paralytic  or  flat  chest.     It  is  a  permanent  bilateral  enlargement 


FIG.   12. — EMPHYSEMATOUS  CHEST. 

of  the  thorax,  and  its  appearance  may  be  simulated  in  the  healthy 
chest  while  at  the  height  of  a  full  inspiration.  We  see  the  abnormal 
fulness  and  roundness,  mainly  above  the  level  of  the  ensiform  car- 
tilage, the  anterior  surface  prominent,  the  dorsal  spine  bent  back- 
ward, as  seen  best  from  the  patient's  side,  and  the  marked  increase 
of  the  anteroposterior  diameter,  equaling  or  exceeding  the  trans- 
verse. The  measurements  and  cyrtometric  or  pantographic  out- 
lines confirm  inspection,  resembling  the  more  circular  shape  of 
the  normal  chest  of  a  child.  The  neck  is  relatively  short,  due 
to  the  raised  shoulders  and  thoracic  case;  the  sternomastoids  and 


INSPECTION 


45 


scaleni  antici  muscles  may  be  visibly  tense,  and  the  chest  as  a  whole 
is  also  diminished  in  length.  The  sternum  is  arched  forward;  the 
ribs  are  thick,  hypertrophic,  massive  looking,  and  run  horizontally 
outward,  consequently  the  epigastric  angle  is  wider — more  obtuse — 
than  normal;  the  intercostal  spaces  above  are  often  full,  while  the 
lower  zone  of  the  thorax  is  frequently  retracted,  especially  during 
inspiration.  The  supraclavicular  regions  are  sometimes  deepened  and 
sometimes  cushiony.  In  many  cases  the  lower  lateral  and  infrascapu- 
lar  regions  bulge  outward  and  backward,  giving  rise  to  the  so-called 
"  barrel-shaped  "  chest.  However,  the  absence  of  this  very  character- 
istic type  of  thorax  does  not  prove  the  absence  of  emphysema  in  all 
cases.  It  indicates  permanent  overdistention  of  the  vesicles  of  the 
lung,  caused  by  prolonged  or  oft-repeated  attacks  of  chronic  bronchitis 
and  asthma. 

Rachitic  Deformities  of  the  Chest. — As  the  result  of  softening 
of  the  bones  due  to  rickets  in  early  childhood,  with  or  without  the 
effects  of  respiratory  diseases  causing  obstruction  to  inspiration,  three 
varieties  of  rachitic  thorax  are  met  with,  namely:  (1)  The  simple 
rachitic  chest,  (2)  the  "pigeon-breast"  (3)  the  transversely  con- 
stricted chest. 

(1)  SIMPLE  KACHITIC  CHEST. — This  type  of  chest  is  shorter  and 
deeper  than  normal.     It  is  characterized  by  a  shallow  depression  or 
groove    on   either   side,    running   downward 

and  outward  in  about  the  anterior  axillary 
line,  causing  the  anterolateral  portions  to 
sink  in  and  the  anteromedian  to  project 
forward,  the  softened,  rickety  ribs  yielding 
(principally  at  the  costochondral  junctions), 
owing  to  lessened  intrathoracic  pressure  dur- 
ing inspiration.  As  shown  in  Fig.  13,  the 
nearly  circular  outline  of  the  healthy  child's 
chest  becomes  almost  quandrilateral  in  the 
rickety.  Another  characteristic  is  the  "  ra- 
chitic rosary,"  or  beadlike  enlargements  of 
the  cartilaginous  (sternal)  ends  of  the  ribs, 
sometimes  easier  felt  than  seen. 

(2)  PIGEON  CHEST. — The  sides  of  the  chest  are  flattened  and  the 
sternum  pushed  and  arched  forward  so  that  the  transverse  outline 
is  triangular,  with  rounded  sides  and  angles   (see  Fig.  14).     The 
protrusion  of  the  sternum  is  most  marked  at  its  lower  portion,  the  ribs 
sloping  sharply  backward  as  the  bow  ribs  of  a  boat  bend  from  its  keel 


FIG.  13.— SIMPLE  RACHITIC 
CHEST.  Dotted  line  in- 
dicates the  shape  of  the 
chest  in  an  infant  about 
same  age. 


46 


PHYSICAL    DIAGNOSIS 


(pectus  carinatum).  This  exaggerated  rachitic  deformity  occurs  after 
diseases  in  which  great  strain  is  thrown  upon  the  lung  by  obstruction 
to  inspiration,  as  from  whooping-cough,  protracted  bronchial  catarrh, 

nasal,  pharyngeal,  or  faucial  en- 
largements (turbinates,  adenoids, 
tonsils).  The  external  atmos- 
pheric pressure  thus  overbalanc- 
ing the  internal,  the  plastic  ribs 
yield  inward  at  their  least  re- 
sistant portions.  Indeed,  the 
pigeon-breast  may  result  from 
such  affections  in  infants  who 
may  not  be  rickety,  especially 
with  the  prolonged  cases  of  broii- 
ehopneumonia  following  measles 
or  pertussis. 

(3)  TRANSVERSELY  CON- 
STRICTED CHEST,  or  HAHRI- 
SON'S  SULCUS. — In  this  form 
the  lower  ribs,  corresponding  to 
the  diaphragmatic  attachment, 
are  drawn  in  below  the  sterno- 
xiphoid  junction,  downward  and 
outward  as  far  as  the  axilla.  Harrison's  groove  is  produced  by 
the  same  causes  as  for  pigeon-chest,  and  the  two  deformities  are 
frequently  associated.  Long-continued  and  hard  coughing  and  in- 
spiratory  difficulty,  by  increasing  the  pull  of  the  diaphragm  upon  the 
flexible,  softened  ribs,  cause  the  deepest  depression  just  above  the 
upper  limits  of  the  liver  and  spleen,  the  resistance  of  the  latter  often 
making  the  lower  margin  of  the  ribs  flare  out.  This  expansion  of 
the  lower  opening  of  the  thorax  may  be  the  result,  however,  of  pres- 
sure from  gaseous  distention  of  the  bowels  (acute  cases),  or  from 
abdominal  dropsy  and  large  tumors.  Again,  it  is  seen  in  some  healthy, 
large-chested  adults. 

The  significance  of  the  detection  of  the  rachitic  types  of  chest  lies 
in  directing  attention  to  the  probable  evidences  of  the  causes  men- 
tioned, and  of  the  respiratory  incapacity  preceding  and  accompanying 
pulmonary  tuberculosis. 

Funnel  Chest  (Trichterbrust). — This  consists  in  a  marked  de- 
pression of  the  lower  part  of  the  sternum,  the  outer  border  of  the 
"  funnel "  being  as  much  as  3  or  4  in.  in  diameter,  and  the  apex 


FIG.  14.  —  TRANSVERSE  SECTION  OF  A 
RACHITIC  CHEST  AT  LEVEL  OF  SIXTH 
THORACIC  VERTEBRA.  Circumference, 
32£  inches;  right  half,  16 J  inches;  ex- 
pansion, 2  inches.  (After  Musser.) 


INSPECTION  47 

from  H  to  3  in.  deep.  It  is  usually  congenital,  and  may  be  asso- 
ciated with  other  physical  and  mental  signs  of  hereditary  or  develop- 
mental faults  and  degeneration.  It  also  may  be  of  rachitic  origin. 

A  sort  of  acquired  funnel  chest,  with  a  sinking-in  of  the  ensiform 
cartilage  chiefly,  is  seen  occasionally  in  cobblers  and  carpenters  who 


FIG.  15. — FUNNEL  BREAST. 


in  early  adolescence  began  to  work  at  their  trades,  and  for  many 
years  used  tools  with  considerable  pressure  over  that  region.  The 
respiration  and  cardiac  action  are  likely  to  be  interfered  with  only 
in  the  congenital  variety. 

(3)   SYMMETRY 

Irregular  Deformities  of  the  Chest. — These  are  caused  by  the  vari- 
ous spinal  curvatures;  inspection  of  the  back  may  reveal  a  Icypliosis, 
or  bending  backward  of  the  spine ;  or  a  scoliosis,  or  bending  sidewise ; 


48 


PHYSICAL    DIAGNOSIS 


or,  more  likely,  a  Jcyphoscoliosis,  or  combination  of  both — i.  e.,  a 
simultaneous  lateral  and  posterior  curvature;  more  rarely,  a  bending 
forward,  or  lordosis,  may  be  met  with.  The  kyphoscoliotic  chest 
witnesses  the  most  distorting  alterations  of  size,  shape,  and  sym- 
metry at  once.  The  spine  is  twisted;  the  upper  dorsal  region  is 
humped;  one  shoulder  is  lower  and  perhaps  more  posterior  than  the 
other;  one  side  is  irregularly  reduced  and  retracted  as  compared  with 
the  other,  and  the  ribs  and  other  thoracic  bones  are  distorted  and 
out  of  relation,  so  that  the  landmarks  and  topographic  relations  of 
the  likewise  compressed  and  displaced  thoracic  organs  are  without 
value  in  diagnosis.  Incidentally,  Pott's  disease  of  the  spine  may 
be  discovered,  as  well  as  abnormal  rigidity  (spondylitis  deformans) 
of  the  vertebra?. 

Chest  deformities  from  curvatures  of  the  spine  are  indicative  of 
susceptibility  to,  and  often  the  presence  of,  tuberculosis,  unilateral 
or  local  emphysema,  pneumonitis,  atelectatic  lung,  pleuritis,  and  de- 
generation and  dilation  of  the  myocardium,  especially  the  right  ven- 
tricular wall. 

Unilateral  Abnormalities  of  Size  and  Shape. — (1)  UNILATERAL 
CONTRACTION  of  the  chest  is  noted  by  observing  (a)  the  general  draw- 

ing-in  and  flattening 
on  one  side;  (&)  the 
intercostal  spaces  are 
both  narrowed  and  de- 
pressed, and  the  ribs 
may  be  so  close  to- 
gether, especially  at 
the  lower  lateral  re- 
gions, as  to  overlap  as 
do  shingles;  (c)  the 
shoulder  on  that  side 
droops;  (d)  the  semi- 
circumference  is  visibly 
and  measurably  dimin- 

FIG.   16. — UNILATERAL  RETRACTION  OF  CHEST,  CONSE-    '      ****»     ^  nllf. 

QUENT  UPON  CIRRHOSIS  OF  LEFT  LUNG,  IN  A  GIRL  OF    affected  side  is  slightly 

FOURTEEN  YEARS.     The  figures  indicate  anteropos-    increaged       Qwing       to 

tenor  and  transverse  diameters  and  semicircumfer- 

ences  of  right  and  left  half  of  chest.  (Gee.)  Compensatory  expan- 

sion ;  (e)  the  mamma 

and  scapula  are  nearer  the  median  line;  (/)  the  spine  is  curved,  with 
its  convexity  toward  the  sound  side.  This  asymmetry  is  caused  by  a 


INSPECTION 


49 


reduction  in  the  size  of  the  lung  either  from  collapse  or  consolidation 
of  the  vesicles;  thus  it  frequently  follows  long-continued  pressure  by 
pleural  effusions,  and  even  after  the  absorption  or  surgical  aspiration 
of  the  liquid,  compression  of  the  lung  is  often  kept  up  by  chronic 
pleuritic  adhesions;  cirrhotic  contraction  of  lung,  or  fibroid  phthisis 
or  interstitial  pneumonia,  as  it  is  variously  termed,  is  a  cause  second 
in  frequency,  the  connective-tissue  thickening  not  only  preventing 
the  lung  from  expanding  with  inspiration,  but,  when  associated  with 
pleuritic  adhesions,  actually  drawing  in  the  chest  wall  by  the  scarlike 
contraction.  This  inward  traction  pulls  upon  the  heart  and  dia- 
phragm also,  with  corresponding  dislocation,  and  decreased  freedom 
of  function.  Less  commonly,  unilateral  shrinking  may  be  the  result 
of  pulmonary  collapse  due  to  some  such  cause  of  a  bronchial  obstruc- 
tion, as  a  foreign  body  within  or  a  pressing  mediastinal  or  pulmonary 
tumor  from  without,  although  a  malignant  growth  may  at  the  same 
time  extend  into  and  occlude  the  lumen  of  a  bronchus. 

(2)  UNILATERAL  ENLARGEMENT  of  the  chest  has  characteristics 
respectively  the  opposite  of  one-sided  flattening — i.  e.,  there  is  dis- 
tinct general  fulness 
or  bulging  on  the  af- 
fected side,  seen  par- 
ticularly from,  the 
front ;  the  intercos- 
tal spaces  are  less  de- 
pressed, and,  as  in 
empyema,  may  be 
decidedly  prominent, 
especially  at  the  base, 
and  widened  also ;  the 
shoulder  may  be 
slightly  elevated;  the 
ribs  may  project  out- 
ward a  little  with 
their  inferior  borders ; 
the  nipple  and  scap- 
ula are  farther  re- 
moved from  the  me- 
dian line;  the  spinal 
bend,  though  slight, 
lias  its  convexity  directed  toward  the  diseased  side  (the  larger,  as 
is  the  sound  side  with  opposite  retraction).  While  the  semicircum- 
6 


31-15  •:.  


FIG.  17. — UNILATERAL  ENLARGEMENT  OF  CHEST  (RIGHT 
SIDE),  ARTIFICIALLY  PRODUCED  BY  INJECTING  AIR 
INTO  THE  RIGHT  PLETIRAL  CAVITY.  Unbroken  line: 
outline  before  injection.  Broken  line:  outline  after 
moderate  distention.  Dotted  line:  outline  after  ex- 
treme distention.  Figures  at  bottom  of  vertical  line 
indicate  the  anteroposterior  diameter;  along  hori- 
zontal line,  transverse  semidiameter;  remaining  fig- 
ures, right  and  left  semicircumferences.  (Gee.) 


50  PHYSICAL    DIAGNOSIS 

ference  measures  larger  on  the  expanded  side,  there  is  simultaneously 
some  increase  on  the  unaffected  side,  though  relatively  less,  on  ac- 
count of  the  pathologic  expanding  force  encroaching  indirectly  upon 
the  healthy  lung  (displaced  heart),  and  so  causing  it  to  exert  greater 
compensatory  effort. 

One-sided  prominence  of  the  thorax  is  very  seldom  the  effect  of 
a  "vicarious  emphysema"  or  dilation  of  the  vesicles,  because  of  dis- 
ease of  the  opposite  lung.  More  frequently  it  is  produced  by  disten- 
tion  with  gas  or  liquid  in  the  pleural  sac;  pneumothorax,  various 
pleural  effusions.  Slight  unilateral  fulness  may  be  seen  in  cases  of 
pneurnonitis  affecting  the  whole  lung.  Great  disparity  between  the 
two  sides  is  readily  observed  in  certain  conditions  in  which  cither 
side  is  enlarged  and  the  other  contracted. 

An  occasional  apparent  symmetry  of  both  sides  of  the  chest  is 
found  even  in  the  presence  of  a  large  pleural  effusion  on  one  side. 
due  to  the  fact  that  the  compensatory  expansion  on  the  unaffected  si< It- 
balances  the  enlargement  on  the  diseased  side. 

Local  Irregularities  of  Form. — (1)  LOCAL  OR  CIRCUMSCRIBED  DE- 
PRESSIONS of  the  thorax  are  most  frequently  noticed  in  the  supra- 
and  infraclavicular  regions,  caused  by  apical  consolidations  or  cavi- 
ties (tubercular),  or  localized  pleuritis.  Extreme  care  must  be  exer- 
cised that  a  slight  flattening  near  the  clavicle  is  not  adjudged  to  be 
from  tuberculosis  when  an  unsymmetrical  position  of  one  arm  or 
shoulder  may  be  the  cause.  A  deepening  on  one  side  of  Morenheim's 
depression,  at  the  outer  part  of  the  infraclavicular  region,  is  a  sign 
of  phthisis.  Flattenings  or  depressions  may  be  seen  over  any  part  of 
the  lungs — anteriorly,  laterally,  or  posteriorly — that  may  be  the  seat 
of  phthisical  or  bronchiectatic  cavities,  circumscribed  pleuritic  adhe- 
sions, abscesses  and  gangrene  of  the  lung.  Two  sources  of  error 
should  be  guarded  against:  apparent  depressions  of  the  chest  due  to 
muscular  w asting ;  relative  deepening  of  the  supra-  and  infraclavicular 
spaces  by  the  projection  of  deformed  clavicles,  the  result  of  healed 
fractures.  Finally,  a  partial  shrinking  may  be  seen,  often  posteriorly, 
at  the  lower  ribs  after  the  absorption  of  a  small  pleuritic  exudation. 

(2)  LOCAL  OR  CIRCUMSCRIBED  BULGINGS  of  the  thorax  are  of  com- 
paratively frequent  occurrence,  particularly  in  the  cardiac  and  aortic 
regions;  in  regard  to  the  latter,  consideration  will  be  given  under 
the  section  dealing  with  heart  affections — with  aneurism  and  eardiac 
enlargements,  for  example. 

In  the  first  place,  local  bulgings  may  be  due  to  pathologic  condi- 
tions in  the  chest  wall — congenital  or  developmental  irregularities  in 


INSPECTION  51 

the  formation  of  the  ribs,  costal  cartilages,  and  their  junctions,  as  from 
spinal  and  rachitic  deformities;  periostitis  and  abscesses  of  the  sub- 
cutaneous cellular  tissue ;  enchondroses  and  actinomycosis  of  the  ribs ; 
lipomatous,  sarcomatous,  carcinomatous,  and  gummatous  tumors  of 
the  chest  wall  or  of  the  lungs,  pleurae,  mediastinum,  or  bronchial 
glands  eroding  and  pushing  their  way  through  the  wall.  Secondly, 
from  within,  localized  emphysema,  cutaneous  or  pulmonary  or  local 
protrusions  of  a  general  emphysema  may  be  seen  in  the  supraclavicular 
regions  or  along  the  upper  anterior  borders  of  the  lungs ;  at  the  base 
of  the  chest  a  localized  prominence,  with  several  smoothed-out  inter- 
spaces and  edematous  skin,  the  pointing  of  a  pleural  abscess  (em- 
pyema),  may  be  met  with;  in  or  near  the  same  region,  encapsulated 
pleuritic  exudations  or  a  circumscribed  pneumothorax  may  exist ;  a 
little  lower  the  bulging  of  a  subphrenic  abscess  may  appear;  finally, 
in  rare  cases,  hydatids  and  hernia  of  the  lung  may  be  thought  of. 

It  should  be  noted  that  prominences  due  to  pleural  and  peri- 
cardial  effusions  are  much  more  apt  to  show  distinctly  in  children 
than  in  adults,  on  account  of  the  greater  flexibility  of  the  ribs  in 
the  former,  so  that  the  absence  of  marked  bulging  in  the  latter  does 
not  preclude  the  possibility  of  a  large  exudation  where  the  walls  are 
more  rigid. 

Care  must  be  exercised  also  not  to  give  pathologic  significance  to 
the  perfectly  natural  slight  prominences  at  the  right  back  inferiorly, 
and  the  precordial  region  in  many  children  and  some  young  adults, 
quite  apart  from  the  asymmetries  of  muscular  development,  espe- 
cially anteriorly. 

(4)   RESPIRATORY  MOVEMENTS 

(1)  Pathologic  Alterations  (Bilateral  or  Symmetrical)  of  the 
Type  of  Respiration. —  (a)  INCREASED  EXPANSION  (predominance 
of  the  thoracic  or  upper  costal  type  of  women). — Whenever  exag- 
gerated thoracic  movement  is  observed  (the  costal  type  in  men,  its 
excess  in  women),  the  first  point  in  the  analysis  is  the  proving  of 
its  physical  genuineness — i.  e.,  the  exclusion  of  voluntary  forced 
breathing  and  of  hysteria.  Briefly,  all  conditions  which  impede  the 
action  of  the  diaphragm  cause  a  relative  increase  in  the  thoracic  type 
of  movement,  and  a  corresponding  decrease  in  the  inspiratory  pro- 
trusion of  the  upper  abdomen. 

Such  diaphragmatic  restriction  is  characteristically  seen  in  cases 
of  inflammation  of  the  pleural  and  peritoneal  serous  membranes  coat- 
ing the  diaphragm  (diaphragmatic  pleurisy;  general  and  local  peri- 


52  PHYSICAL    DIAGNOSIS 

tonitis),  and  of  mechanical  restraint  due  to  increased  upward  pressure 
within  the  abdomen.  Among  the  principal  causes  of  the  latter  are 
gaseous  distention  of  the  intestines,  ascites,  and  great  enlargements 
of  the  liver  or  spleen,  or  other  abdominal  tumors;  advanced  preg- 
nancy is  a  frequent  cause.  Besides  these,  the  weight  of  a  large  peri- 
cardial  effusion  may  prevent  free  action  of  the  diaphragm,  and  thus 
cause  exaggerated  thoracic  movement;  sometimes  the  failure  of  the 
diaphragm  to  act  on  the  left  side  in  such  cases  can  be  detected  by 
noticing  the  sucking-in  of  the  lower  interspaces  with  inspiration  on 
that  side.  Again,  complete  absence  of  costo-abdominal  movement 
from  paralysis  of  the  diaphragm,  the  result  of  a  severe  diffuse  peri- 
tonitis or  of  a  bulbar  palsy  or  of  paralysis  of  the  phrenic  nerves  occur- 
ring with  multiple  neuritis  or  spinal  pachymeningitis ;  here  the  upper 
costal  movement  is  excessive,  and  instead  of  epigastric  protrusion 
during  inspiration  there  is  general  retraction,  followed  by  apparent 
protrusion  with  expiration  as  the  chest  wall  recoils. 

( b )  DIMINISHED  EXPANSION,  on  the  other  hand,  with  exaggerated 
abdominal  respiratory  movement,  may  be  a  simple  or  direct  diminution 
of  simultaneous  expansion  and  elevation,  or  the  diminution  may  be  due 
to  a  modified  relation  of  the  movement  of  expansion  to  that  of  eleva- 
tion, causing  a  changed  character  of  thoracic  breathing.  Instances 
of  the  former  are  observed  in  lack  of  development,  ordinary  debility, 
paralysis  of  the  chest  muscles,  tuberculosis  of  the  lungs,  tetanic  spasm 
of  the  chest  muscles,  whether  from  disease  (tetanus)  or  strychnic 
poisoning;  rarely,  in  association  with  the  conditions  of  rigidity  and 
thickening  of  the  thorax  due  to  myositis  ossificans  and  scleroderma. 

General  diminished  expansion  may  also  be  an  indication  of  partial 
or  complete  obstruction  to  the  entrance  of  air  into  the  lungs.  The 
causes  of  this  condition  may  reside  in  (1)  the  larynx,  trachea,  or 
larger  bronchi;  (2)  the  smaller  bronchi;  or  (3)  the  pulmonary  vesi- 
cles. Severe  spasmodic  or  membranous  laryngitis,  paralysis  of  the 
vocal  cords,  laryngeal  tumors,  acute  laryngotracheitis  and  bronchitis, 
and  the  pressure  of  tumors  from  without  these  upper  respiratory  pas- 
sages, are  examples  of  the  first.  Under  the  second,  spasmodic  or 
bronchial  asthma,  and  the  deep-seated  bronchitis  of  influenza,  or  as 
frequently  seen  in  the  two  extremes  of  life,  are  common  examples. 
Obstructions  occurring  under  the  third  head  may  be  either  within  or 
without  the  lung  vesicles;  of  the  former,  we  have  double  or  bilateral 
pneumonic  consolidation,  tuberculosis,  and  pulmonary  collapse  as 
causes;  of  the  latter,  double  hydrothorax.  Besides  these,  it  should 
be  noted  that  the  general  thoracic  movement  may  be  diminished  as 


INSPECTION  53 

the  result  of  pain  during  breathing  in  cases  of  acute  pleuritis,  pleuro- 
dynia,  or  intercostal  neuralgia. 

Again,  in  the  emphysematous  chest  the  normal  respiratory  move- 
ment is  diminished  because  characteristically  modified  or  replaced  by 
an  up-and-down  heaving  of  the  thorax  as  a  whole.  It  is  here  that 
the  relation  of  expansion  to  that  of  elevation  is  so  altered  that  the 
former  is  practically  in  abeyance,  and  the  rigid  chest  moves  vertically 
only.  This  abnormity  of  movement  depends  upon  the  fact  that  the 
lungs  are  constantly  overdistended  with  air  because  the  vesicles  have 
lost  their  elasticity,  and  hence  their  expulsive  force.  The  air-filled 
vesicles  permit  of  no  further  expansion,  therefore  the  forced  effort 
to  do  so  produces  simply  an  exaggeration  of  the  mere  dragging  up- 
ward of  the  thorax  seen  in  normal  forced  inspiration.  "  The  inspira- 
tory  movement  must  be  made  '  on  the  top  of  inspiration ' ;  that  is, 
plus  a  degree  of  inflation  of  the  lungs  that  in  health  should  be 
approached  only  toward  the  end  of  inspiration"  (Steell). 

We  observe  simultaneously  with  the  upward  movement  of  the 
upper  part  of  the  chest  that  there  is  anterolateral  retraction  of  the  epi- 
gastric and  lower  costal  regions  during  the  inspiratory  effort,  owing 
to  the  forcible  descent  of  the  diaphragm  not  being  followed  by  the 
expansion  of  the  lower  lobes  of  the  lungs,  and  the  external  atmos- 
pheric pressure  thus  overcoming  the  weaker  internal. 

Expiratory  chest  movement  is  attended  with  even  greater  diffi- 
culty (dyspnea)  than  the  inspiratory;  it  is  imperfect,  slow,  and  ex- 
tremely prolonged.  Obviously  this  is  because  of  the  diminished  elas- 
ticity of  the  lungs,  aided  in  many  cases  by  obstruction  to  the  egress 
of  air  from  bronchitic  exudation  in  the  tubes,  and  sometimes  by 
downward  displacement  of  the  diaphragm. 

(c)  RECESSION  OF  THE  LOAVER,  ANTEROLATERAL  INTERCOSTAL 
SPACES  during  inspiration,  instead  of  expansion,  is  characteristic  of 
obstruction  of  the  upper  respiratory  passages,  especially  of  the  larynx, 
as  from  spasm  of  the  glottis,  edema  of  the  larynx,  diphtheritic  laryn- 
gitis, and  the  like.  This  inspiratory  retraction  of  the  lower  zone  of 
the  chest  is  most  manifest  in  children,  where  the  upper  epigastric 
region,  as  well  as  the  interspaces,  may  be  drawn  in  considerably  from 
obstruction  above  the  bifurcation  of  the  trachea.  The  inspiratory 
expansion  of  the  upper  thorax  is  forcibly  made  for  even  the  little  air 
that  finds  its  way  into  the  upper  lobes  of  the  lungs;  diaphragmatic 
contraction  is  also  greatly  intensified,  with  marked  abdominal  pro- 
trusion, but  as  there  is  not  sufficient  air  to  inflate  the  lower  lobes, 
their  collapse  allows  the  atmospheric  pressure  to  drive  in  the  inferior 


54 

parts  of  the  chest.  This  may  be  witnessed  in  extensive  broncho- 
pneumonitis  of  both  lungs,  as  well  as  in  emphysema,  mentioned  under 
the  previous  heading;  and  it  is  the  prolonged  strain  of  the  persist- 
ence of  the  former  of  these  two  in  children  with  rachitic,  rib-yielding 
chests  that  leads  to  the  permanent  transversely  constricted  and 
pigeon  chest. 

(2)  Unilateral  Abnormities  of  Movement. — UNILATERAL  DIMINU- 
TION OF  MOVEMENT  is  best  exemplified  in  large  pleuritic  effusions 
on  one  side.     The  abeyance  of  movement  may  be  associated  with 
simultaneous  unilateral  enlargement  or  retraction  of  the  chest,  or 
without  any  visible  change  to  either  abnormity.     Diminished  expan- 
sion, or  even  virtual  absence  of  one-sided  movement,  with  abnormal 
fulness  on  that  side,  is  seen  in  extensive  pleural  exudations  and  in 
pneumothorax,    and    slightly    in    massive    pneumonic    consolidation. 
The  principal  causes  of  unilateral  decreased  movement  with  retraction 
of  the  affected  side  are  fibroid  phthisis,  partial  or  complete  collapse 
of  lung  from  old  pleuritic  adhesions  or  from  pressure  on  a  main 
bronchus  by  a  tumor  or  aneurism.     In  cases  of  acute  pleuritis  in  the 
early  stage  (before  liquid  effusion)   restriction  of  movement  on  one 
side  without  any  alteration  of  its  size  or  shape  is  usually  met  with 
on  account  of  the  nervous  reflex  influence  of  the  pain  of  breathing; 
also  in  cancerous  infiltration  of  the  lung. 

What  slight  movement  may  exist  with  the  unilateral  diminution 
is  that  of  elevation  rather  than  of  expansion,  such  as  difficult  respira- 
tion generally  produces.  The  opposite  or  unaffected  side  usually  shows 
compensatory  increase  of  action. 

UNILATERAL  INCREASED  EXPANSION,  as  just  stated,  is  a  signal 
indication  of  incapacitated  or  diseased  lung  on  the  other  side,  and 
consequently  represents  vicarious  action,  or  "compensatory  emphy- 
sema," from  the  temporarily  exaggerated  distention  of  the  pulmonary 
vesicles.  The  contrast  between  the  overacting  healthy  and  under-  or 
nonacting  diseased  side  is  the  more  readily  detected  by  noting  the 
sharp  inspiratory  onset,  and  more  rapid  and  vigorous  movement  of 
the  former. 

(3)  Local  Abnormities  of  Movement. — LOCAL  DIMINUTION  or 
MOVEMENT  is  most  characteristically  observed  in  the  lagging  breath- 
ing of  tubercular  consolidation  of  the  apices  of  the  lungs,  especially 
in  the  infraclavicular  depressions.     The  indication  of  this  condition 
on  either  side  is  a  delayed  as  well  as  diminished  inspiratory  move- 
ment.    Local  flattening  or  sinking-in  accompanies  the  lagging  de- 
ficiency of  movement;  this  is  true  of  localized  pleurisies  (adhesive) 


INSPECTION  55 

as  well  as  phthisical  consolidations  of  the  upper  lobes.  Sometimes 
a  tuberculous  cavity  may  be  diagnosed  by  noting  a  slight  trembling 
or  napping  of  the  thin  overlying  intercostal  tissues  in  emaciated 
subjects.  Circumscribed  diminution  of  expansion  of  the  upper  thorax 
may  also  be  due  to  apical  pneumonitis.  At  the  base,  with  some 
fulness  of  the  interspaces  the  deficient  movement  may  be  caused  by 
lobar  pneumonitis  or  a  small  quantity  of  pleural  effusion.  In  chil- 
dren suffering  from  bronchopneumonitis,  small  portions  of  consoli- 
dated and  collapsed  (atelectatic)  lung  may  be  localized  by  the  dis- 
covery of  such  little  areas  of  defective  movement. 

LOCAL  INCREASED  MOVEMENT  is  compensatory  to  circumscribed 
impaired  action  on  the  same  side ;  thus,  an  increased  expansion  of  the 
upper  part  of  the  chest  on  the  right  side,  with  restriction  at  the  base, 
is  an  indication  of  pneumonic  consolidation  of  the  right  lower  lobe, 
or  possibly  of  a  pleural  effusion.  Again,  when  the  apex  of  a  lung  is 
the  seat  of  a  tuberculous  infiltration,  the  respiratory  movement  of  the 
lower  part  of  the  affected  side  is  visibly  increased. 

ABNORMAL  PULSATIONS  AND  RESPIRATORY  BULGINGS. — These  are 
likewise  local  physical  signs.  Rarely,  pulsations  of  the  heart  may  be 
seen  in  the  left  mammary  or  axillary  regions  due  to  overlying  infil- 
trated lung  or  an  accumulation  of  pleuritic  pus  (pulsating  empyema), 
to  and  through  which  the  cardiac  impulse  is  transmitted.  Such  com- 
municated pulsations  are  to  be  differentiated  from  hypertrophy,  dis- 
location, and  aneurism  of  the  heart  and  aneurism  of  the  descending 
aorta. 

Insplraiory  bulging  may  be  seen  above  the  clavicles  and  near  the 
upper  edges  of  the  sternum  in  considerable  vesicular  enlargement  of 
emphysema. 

Expiratory  bulging  of  the  supraclavicular  and  intercostal  spaces 
is  more  common  in  emphysema  and  asthma  on  account  of  the  diffi- 
culty in  emptying  the  lungs  during  the  costal  depression;  in  cases 
of  large  lung  cavities,  the  walls  of  which  are  adherent  to  the  chest 
wall,  bulging  of  the  upper  interspaces  during  expiration,  especially 
when  forced,  may  also  be  observed  in  advanced  tuberculosis. 

Finally,  an  inspiratory  fall  and  an  expiratory  rise  in  the  bulging 
of  the  lower  interspaces  may  sometimes  be  seen  as  an  index  of  the 
weakening  of  the  intercostal  muscles  by  the  accumulation  of  a  suffi- 
ciently great  quantity  of  liquid  in  the  pleural  sac,  or  the  pleura  and 
muscles  may  even  be  ruptured  so  that  the  swelling  is  quite  subcu- 
taneous. 

Circumscribed  thoracic  pulsation  may  be  due  to  a  tumor  in  prox- 


56  PHYSICAL    DIAGNOSIS 

imity  to  the  heart.  Sailer  describes  a  case  of  distinct  expansile 
pulsation  over  the  whole  left  thorax  which  autopsy  showed  to  he 
caused  by  a  ruptured  aneurism  of  the  ascending  and  transverse  por- 
tions of  the  arch  of  the  aorta,  with  left  hemothorax. 

Stillcr's  Intercostal  Phonation  Phenomenon. — The  simultaneous 
bulging  of  the  intercostal  spaces  during  phonation  is  held  by  Stiller 
to  be  a  useful  adjunct  in  the  physical  diagnosis  of  a  pleural  effusion 
and  its  differentiation  from  consolidation  of  the  lung.  The  phenome- 
non also  enables  one  to  trace  the  line  of  demarcation  of  liver  and 
spleen.  It  is  best  elicited  if  the  patient  closes  his  nostrils  and  places 
his  hand  over  the  mouth  to  partially  obstruct  the  expired  air.  Forced 
expiration  should  also  be  practised  before  phonation  is  attempted 
(Abrams). 

(4)  Degree  of  Respiratory  Expansion. — In  doubtful  instances  of 
bilateral,  unilateral,  or  local  alterations  of  thoracic  movement,  or 
whenever  inspection  requires  the  aid  of  additional  accuracy,  mensura- 
tion is  resorted  to,  and  the  precise  degree  of  expansion  compared  with 
the  normal.  If  the  amount  of  expansion  is  less  than  2  in.  in  the 
male  and  2|  in.  in  the  female,  it  is  below  the  normal  average  re- 
spectively. 

An  expansion  of  but  1£  in.  in  a  large  chest  in  one  who  has  or 
has  had  frequent  attacks  of  asthma  or  bronchitis,  points  to  the  de- 
velopment of  emphysema;  in  marked  cases  the  diminution  may  be  to 
even  £  in.  In  small  chests,  as  the  phthisical,  the  degree  of  expansion 
varies  from  1  to  2  in.  in  most  of  the  cases. 

Semicircumferential  diminution  of  expansion  is  noted  over  pleural 
effusions,  pneumothorax,  chronic  pleuritic  adhesions,  and  fibroid 
shrinking  of  the  lung.  In  acute  pleuritis  and  lobar  pneumonitis  there 
is  reduced  measurement,  almost  to  a  temporary  abolition  of  motion, 
on  account  of  intense  pain  and  mechanical  interference  causing  partly 
reflex  and  partly  voluntary  restriction. 

Local  diminution  of  expansion  is  seldom  a  mensurable  factor  of 
importance  except  in  occasional  cases  of  early  pulmonary  tubercu- 
losis. Here  observation  may  be  aided  by  measuring  the  anteroposterior 
apical  expansion  on  both  sides  with  the  thoracometer,  one  arm  of 
which  is  applied  below  the  middle  of  the  clavicle  and  the  other  upon 
the  spine  of  the  scapula,  care  being  taken  that  both  extremities  of  th'e 
instrument  are  equidistant  from  the  median  line  of  the  chest.  In  a 
case  of  apical  consolidation  or  excavation  on  one  side,  for  example, 
the  diminished  respiratory  excursion  may  readily  be  measured,  so 
that  the  forward  movement  on  the  affected  side  during  quiet  breath- 


INSPECTION  57 

ing  may  be  abolished  or  scarcely  perceptible  on  the  scale,  instead  of 
indicating  from  -£$  to  -fa  of  an  inch  (Sibson),  or,  during  forced 
inspiration,  may  register  decidedly  less  than  |  to  2  in. 

(5)  Abnormal  Vital  Capacity. — Mensuration  of  the  capacity  for 
air  by  means  of  the  spirometer,  although  not  of  absolute  value  in 
diagnosis,  may  be  of  considerable  service  in  watching  the  course  of 
a  given  case  of  pulmonary  affection  by  taking  frequent  measurements, 
and  so  better  estimating  the  probable  outcome;  it  supplements  the 
other  methods  of  physical  examination  in  comparing  present  with 
past  data;  also  affords  indications  of  the  general  soundness  and  en- 
during qualities  of  groups  of  men,  such  as  those  about  to  enlist  in 
the  army  and  navy,  or  candidates  for  gymnastic  contests  or  field 
and  aquatic  sports.  In  view  of  the  many  conditions,  including  ana- 
tomical and  physiological  peculiarities,  habits,  occupation,  the  state 
of  the  abdominal  organs,  etc.,  that  may  affect  the  vital  capacity  aside 
from  thoracic  disease,  the  best  available  criterion  is  its  relation  to 
body  height.  Otis  and  Hitchcock  found  in  24,000  measurements  an 
average  lung  capacity  in  general  of  about  236  cu.  in.  The  average 
lung  capacity  of  a  young  male  adult  5  ft.  7  or  8  in.  in  height  is 
237.10  cu.  in.;  that  of  one  5  ft.  8  or  9  in.,  244.44  cu.  in.;  one  5  ft. 
10  or  11  in.,  261.38  cu.  in.  The  general  average  is  3^  cu.  in.  for 
each  inch  of  height,  or  23.19  c.c.  for  each  centimeter  of  height.  In 
women,  the  average  capacity  for  average  height  is  from  145  to  150 
cu.  in.,  or  2.3  cu.  in.  for  each  inch  of  stature. 

Any  decided  fall  below  the  general  average  of  lung  capacity  justi- 
fies a  suspicion  of  tuberculosis,  though  it  does  not  warrant  a  positive 
diagnosis  as  an  independent  observation.  In  fact,  the  spirometer 
indicates  only  the  deficient  supply  of  air  without  really  pointing  out 
which  of  many  causes  produces  the  deficiency,  or  in  what  portion 
of  the  lungs  the  deficiency  is  located.  Whether  the  diminution  of 
vital  capacity  is  due  to  weak  or  diseased  lungs  or  to  the  fallacious 
results  of  ignorant  or  intentional  incoordination  of  breathing  in 
making  the  test  in  certain  individuals,  the  need  for  instructions  in 
respiratory  gymnastics  in  either  case  is  clearly  indicated.  It  should 
be  borne  in  mind  that  a  convalescing  patient  increases  in  vital  capacity 
with  practise  as  well  as  with  the  general  course  of  improvement.  The 
degree  of  diminution  of  spirometric  measurement  varies,  of  course, 
with  the  extent  and  intensity  of  the  pathologic  interference  with  the 
lung  action;  that  is,  whether  the  disease  is  narrowly  circumscribed, 
one-sided,  or  bilateral,  and  whether  it  is  severely  acute  and  rapid 
in  course,  like  lobar  pneumonitis,  or  the  reverse,  like  emphysema. 


58  PHYSICAL    DIAGNOSIS 

(C)  The  degree  of  respiratory  pressure,  as  obtained  by  the  prieu- 
matomcter,  is  so  closely  related  to  that  of  expansion  that  brief  refer- 
ence to  it  may  be  made  here.  Its  results  are  more  variable  than 
those  obtained  by  spirometry;  but  they  have  auxiliary  value,  never- 
theless, in  estimating  either  the  severity  of  disease  or  its  tendency  to 
improvement  or  aggravation.  In  health,  the  expiratory  pressure, 
owing  to  the  muscular  force  that  may  be  exerted,  is  greater  than 
the  inspiratory  in  about  the  ratio  of  7-i  to  5. 

Diminution  of  inspiratory  pressure  in  stenosis  of  the  respiratory 
passages  and  in  pleuritis  with  fibrinous  or  liquid  exudation  (from 
pain  or  mechanical  interference)  are  naturally  concomitant.  In  pul- 
monary tuberculosis,  especially  in  the  earlier  stages,  the  progress  of 
the  disease  may  be  watched  to  advantage  by  noting  the  changes  in  the 
diminished  pressure  of  inspiration. 

Of  more  diagnostic  significance,  however,  is  diminished  expiratory 
pressure,  observed  in  emphysema,  where  the  degree  of  diminution 
measures  the  degree  of  loss  of  elasticity  and  tension  of  the  vesicles 
of  the  lung. 

(5)   LITTEN'S  SIGN 

As  intimated  before,  we  have  in  the  observation  of  this  sign  of 
the  moving  phrenic  shadow  a  ready  and  fairly  reliable  means  of 
judging  of  pathologic  diminutions  of  respiratory  capacity  without 
apparatus. 

Bilateral  decrease  of  the  moving  phenomenon,  and  consequently 
of  the  downward  propulsion  of  the  diaphragm  may  mean  either  a 
tubercular  predisposition,  or  actual  disease,  or  moderate  emphysema; 
if  the  former,  the  characteristic  small  or  phthisical  chest  is  associated, 
and  if  the  latter,  the  enlarged,  barrel-shaped  chest.  Great  general 
debility  and  muscular  weakness  from  prolonged  illness  of  various 
kinds  may  also  manifest  diminished  but  not  absent  excursion  of  the 
shadow. 

One-sided  diminution  of  the  diaphragm  shadow  may  mean  small 
pleuritic  effusion,  pneumonia  of  the  lower  lobe,  or  pleuritic  adhesions, 
the  effect  being  to  lower  the  point  at  which  the  shadow  begins  to 
move  by  an  interspace  or  two.  The  special  value  of  Litten's  sign 
is  in  the  differential  diagnosis  between  a  liquid  pleural  effusion  on 
the  right  side  and  a  subdiaphragmatic  abscess  or  upward  enlargement 
of  the  liver;  the  absence  of  the  phenomenon  in  the  first-named  con- 
dition is  thus  distinctly  helpful,  being  especially  indicative  of  large 
fluid  accumulations. 


INSPECTION  59 

Only  very  large  tumors  below  the  diaphragm  or  very  large  quan- 
tities of  ascitic  fluid  interfere  sufficiently  with  the  descent  of  the 
diaphragm  as  to  abolish  the  moving  shadow. 


(6)   ABXORMAL   RATE  AND  RHYTHM  OF  RESPIRATION- 
DYSPNEA 

Alterations  of  the  frequency  and  regularity  of  the  breathing  move- 
ments give  rise  to  more  or  less  dyspnea,  or  "  shortness  of  breath/' 
at  once  an  objective  as  well  as  subjective  symptom,  and  here  con- 
sidered because  closely  associated  with  the  physical  signs  proper  of 
thoracic  diseases,  although  it  may  be  caused  by  many  conditions  out- 
side of  the  chest.  Pathologic  dyspnea  is  the  counterpart  of  the 
physiologic  shortness  of  breath  produced  by  intense  exertion,  as  a 
sharp  run  up-stairs,  or  by  fulness  of  the  stomach  after  a  too  con- 
vivial meal;  it  is  an  abnormal  increase  of  respiratory  activity. 

Anomalies  of  Frequency. — SIMPLE  ACCELERATION  of  the  respira- 
tory rate  is  a  feature  observed  in  almost  every  variety  of  disease  of 
the  respiratory  organs;  at  the  same  time,  it  should  be  noted  that 
laborious  breathing,  or  true  dyspnea,  is  also  nearly  always  increased 
in  frequency.  Although  abnormally  rapid  breathing  is  secondarily 
suggestive  of  other  than  pulmonary  conditions,  such  as  various  febrile 
states — especially  in  children—hysteria,  toxemic  conditions,  anemia, 
certain  cardiac  diseases,  etc.,  these  are  more  appropriately  dealt  with 
in  works  on  general  medical  diagnosis. 

Anything  which  completely  or  partially  obstructs  the  flow  of 
respiratory  air  may  accelerate  the  breathing.  Thoracic  conditions 
causing  painful  breathing,  of  course,  may  cause  abnormally  rapid 
respiration  independent  of  much  mechanical  interference  with  the 
flow  of  tidal  air,  or  may  aggravate  it.  Thus,  inflammation  of  the 
pulmonary,  costal,  or  diaphragmatic  pleura,  with  or  without  pneu- 
monitis,  is  a  common  example  of  hyperpnea,  as  abnormally  frequent 
respiration  is  sometimes  termed.  The  respiratory  affections  that  give 
rise  to  acceleration  of  breathing  movements  likewise  produce  dyspnea, 
and  will  be  enumerated  later. 

ABNORMALLY  SLOW  RESPIRATION  (Jiypopnea)  is  usually  associated 
with  stenosis  of  the  larynx,  as  from  tumors  within  or  pressing  from 
without,  foreign  bodies  in  the  trachea,  and  so  on.  Again,  even  in 
cases  where  the  air-space  in  the  pulmonary  vesicles  is  diminished  in 
some  portions,  provided  the  interference  with  respiration  is  gradually 
produced  by  a  chronic  process,  slowing  of  the  breathing  is  more 


60  PHYSICAL   DIAGNOSIS 

characteristic  than  rapidity,  the  patient  heirig  at  rest.     This  is  seen 
in  chronic  fibroid  phthisis. 

Anomalies  of  Rhythm. — (1)  SIGHING,  or  the  occasional  deep  in- 
spiration followed  hy  a  rapid  and  broken  expiration,  is  a  temporary 
irregularity  of  breathing  often  met  with  in  healthy  persons,  sitting  or 
sleeping,  but  who  are  not  inhaling  sufficient  oxygen  constantly.  It 
indicates  at  times  deficient  respiratory  capacity  from  habits  of  poor 
expansion  due  to  sedentary,  stooping  occupations  and  neglect  of 
corrective  exercise. 

(2)  SIMPLE  IRREGULARITY. — There  are  several  varieties  of  irregu- 
larity of  rhythm  met  with.     Thus,  the  respiratory  movements  may 
be  (a)   abnormally  shallow  and  irregular  in  the  time  intervals;   (&) 
abnormally  deep  and  irregular;  (c)  spasmodic,  jerky,  and  restrained. 
The  first  is  seen  in  conditions  of  collapse,  as  in  the  terminal  stages 
of  pulmonary  tuberculosis.    The  second,  besides  being  sometimes  asso- 
ciated with  the  abnormally  full  breathing  in  certain  diabetics — the 
so-called  diabetic  dyspnea — is  not  infrequently  observed  in  patients 
suffering  from  acute  miliary  tuberculosis  of  the  lungs.     The  third 
is  most  commonly  inspiratory.     It  is  especially  characteristic  in  the 
"  catch  "  or  "  stitch  "  or  "  hot  needle  thrust  "  in  the  side  of  a  begin- 
ning or  dry  pleuritis,  acute  pneumonitis,  pleurodynia,  or  intercostal 
neuralgia.     Instead  of  a  continuous  movement,  the  pain  causes  a 
sudden  interruption  or  several  interruptions  of  the  inspiration  which 
are  easily  noticeable;  they  may  also  be  evident  in  asthma  and  in 
hysteria.     Jerky  expiration  is  seen  in  some  cases  of  pleurodynia  and 
pleuritis,  also,  as  well  as  from  fractured  ribs. 

(3)  CHANGED    BELATION   OF    INSPIRATION-EXPIRATION    KATIO. 
ASTHMATIC  BREATHING. — A  shortened  inspiration  is  often  charac- 
teristic of  acute  pneumonitis,  and  thus  causes  a  lengthening  of  the 
pause,  just  before  the  expiration,  that  may  be  quite  decided. 

The  difficult  breathing  of  an  asthmatic  attack  is  marked  by  a 
reversal  of  the  normal  rhythm,  so  that  the  expiration  is  longer  instead 
of  shorter  than  the  inspiration.  The  expiratory  movement  of  the 
emphysematous  chest  is  also  relatively  prolonged,  but  there  is  not 
the  exaggerated  use  of  the  accessory  muscles  of  respiration  seen  during 
an  asthmatic  paroxysm. 

Increased  length  of  inspiration  is  manifest  in  obstruction  of  the 
larynx  or  trachea;  recession  of  the  lower  intercostal  spaces  and  in- 
creased expansion  of  the  upper  thorax  accompany  this  sign. 

(4)  CHEYNE-STOKES  BREATHING,  although  associated  more  fre- 
quently with  cerebral  and  renal  than  cardiac  and  pulmonary  affec- 


INSPECTION  61 

tions,  is  always  a  unique  and  seriously  significant  alteration  of  the 
respiratory  rhythm.  The  respiratory  movements  become  gradually 
slower  and  shallower  until  a  period  of  cessation  or  apnea  ensues. 
This  is  followed  by  a  very  feeble  respiration,  then  more  quickly  a 
stronger  one,  the  succeeding  movements  becoming  gradually  deeper 
and  quicker  and  noisier  until  pronouncedly  dyspneic  in  character. 
These  exaggerated  respirations  then  decline  in  amplitude  and  rapidity 
again  as  before.  The  whole  cycle  of  ascending  and  descending  phases 
and  pause  lasts  from  a  half  to  two  minutes,  the  pause  occupying  about 
half  the  period.  During  this  apneic  pause  consciousness  is  nearly  or 
quite  abolished,  and  the  pupils  are  contracted  and  immobile  to  light; 
with  the  return  of  deeper  breathing  consciousness  returns  and  the 
pupils  begin  to  dilate  and  react  to  light.  At  the  height  of  the  regular 
dyspneic,  deeply  sighing,  or  snoring  breathing  the  pupils  may  be 
wildly  dilated. 

Cheyne-Stokcs  respiration  is  usually  more  noticeable  when  the 
patient  is  quietly  sleeping  or  comatose.  There  are  several  minor 
modifications  of  the  type ;  thus,  ordinary  deep  respirations  may  simply 
alternate  with  a  regularly  recurring  apncea,  or  the  recurrences  of  super- 
ficial and  exaggerated  breathing  may  be  minus  the  periods  of  pause. 

Dyspnea. — Here  belongs  a  further  and  more  definite  reference  to 
difficult  or  laborious  breathing,  to  its  physical  varieties  and  their 
causation;  for,  as  just  indicated,  the  chief  characteristic  of  dyspnea 
is  an  increase  in  the  frequency  and  depth  of  the  respirations,  or  both,, 
anomalies  of  rate  and  of  rhythm. 

INSPIEATORY  dyspnea  (meaning  purely  or  dominantly  a  difficult 
entrance  of  air)  is  recognized  by  the  increased  energy  and  rapidity 
of  the  inspirations.  They  may  be  aggravated  and  interrupted  by 
pauses  to  recover  the  breath  on  account  of  the  least  exertion,  such  as 
speaking,  sitting  up,  etc.  In  severe  cases  the  accessory  inspiratory 
muscles  are  brought  into  active,  almost  tetanic  contraction  (the  sterno- 
cleidomastoid,  scaleni,  pectoralis  major  and  minor,  the  levatores 
costarum,  serratus  posticus  superior,  rhomboideus,  trapezius,  and  leva- 
tores  scapulas).  In  various  degrees  it  is  the  result  of  some  obstruction 
in  or  about  the  upper  respiratory  passages.  It  is  present  in  paralysis 
of  the  posterior  crico-arytenoid  muscles  (dilators  of  the  glottis),  in 
spasmodic  and  membranous  croup  and  edema  of  the  larynx,  in  which 
the  characteristic  harsh,  shrill,  whistling,  screeching,  crowing,  or 
barking  inspiratory  sound  is  heard;  it  is  known  also  as  stridulous 
breathing,  or  stridor.  Similarly,  laryngeal  and  tracheal  obstruction 
from  foreign  bodies  (dyspnea  sudden)  and  tumors  within,  and  pres- 


62  PHYSICAL    DIAGNOSIS 

sure  from  the  latter  without,  prodiu-e  inspirator}'  dyspnea.  In  ex- 
treme cases  there  is  usually  at  the  same  time  inspiratory  retraction 
of  the  lower  interspaces  and  epigastrium,  and  even  the  upper  and 
supraclavicular  spaces. 

The  croupous  bronchitis  and  bronchopneumonitis  of  children  give 
a  typical  picture  of  inspiratory  dyspnea. 

Similar  results  happen  when  conditions  arise  suddenly  or  grad- 
ually that  diminish  the  air-space  or  disturb  the  "  volumetric  varia- 
tion "  of  the  lungs.  Thus,  perforation  of  the  pleura  over  a  tubercu- 
lous cavity,  and  consequent  collapse  of  the  lung  from  pneurnothorax ; 
sudden  or  rapid  congestion  or  edema  of  the  lungs,  or  effusion  into 
the  pleural  sac ;  the  occluding  pressure  of  aneurismal  and  mediastinal 
tumors;  thrombosis  and  embolism  of  the  pulmonary  artery;  kypho- 
scoliotic  deformity  of  the  chest,  interfering  with  the  extent  of  breath- 
ing surface,  and  abdominal  enlargements  which  push  up  the  diaphragm 
considerably. 

EXPIRATORY  dyspnea  is  characterized  by  a  prolonged,  labored, 
often  wheezy  expiration.  The  abdominal  muscles,  the  quadrat  us  luiii- 
borum,  and  the  serratus  posticus  inferior  are  accessory  muscles.  This 
variety  of  dyspnea  may  be  caused  by  movable  tumors  obstructing  the 
trachea  and  bronchi,  but  is  due  principally  to  asthma  and  emphysema. 

MIXED  inspiratory  and  expiratory  dyspnea  is  very  frequent,  and 
occurs  in  most  of  the  respiratory  and  cardiac  affections  at  some  time 
or  other. 

ORTHOPNEA  (Gr.,  orthos,  straight,  upright)  is  an  exaggerated 
form  of  dyspnea  requiring  an  upright  posture  for  the  purpose  of 
getting  the  breath.  The  accessory  muscles  of  respiration  are  strongly 
active,  and  the  short,  quick,  heaving  efforts  witness  to  the  gravity 
and  distress  of  the  condition.  The  sitting  or  standing  position  en- 
ables the  patient's  thorax  to  move  with  the  greatest  freedom,  and  the 
auxiliary  muscles  to  act  better.  Orthopnea  is  a  usual  sign  of  cardiac 
disease  in  the  advanced  stages,  when  the  "  broken  compensation  "  on 
the  part  of  the  muscular  walls  of  the  heart  results  in  pulmonary 
congestion,  and  later  in  dropsy  of  the  lower  extremities  and  conges- 
tion of  the  abdominal  viscera.  In  bad  cases  of  asthma  and  emphy- 
sema, also,  and  in  severe  fibrinous  bronchitis,  bilateral  pleural  effu- 
sions, and  double  pneumonites,  the  up-and-down  instead  of  the  ex- 
pansile movement  of  the  chest  in  the  sitting  posture  is  a  common 
observation,  especially  in  the  medical  wards  of  a  large  hospital.  In 
cardiac  orthopnea,  the  in-and-out  movements  of  the  ribs,  though  ex- 
aggerated, are  much  better  maintained  than  in  the  respiratory  form. 


PALPATION 

To  learn  more  about  the  physical  characteristics  of  what  one  sees, 
one  instinctively  and  almost  simultaneously  puts  forth  the  hands  to 
feel  whether  vision  has  been  true  and  sufficient  or  incomplete  and 
inexact.  Xaturally,  then,  the  method  of  trained  touch,  or  palpation, 
conies  close  upon  the  heels  of  inspection  to  corroborate,  modify,  and 
enlarge  the  knowledge  gained  by  the  latter.  However,  a  sensitive, 
educated  touch  is  not  only  useful  in  aiding  the  sense  of  sight,  by 
confirming  and  amplifying  the  results  of  inspection;  it  has  inde- 
pendent value,  also,  in  furnishing  decisive  evidence  that  even  the 
more  exact  methods  of  percussion  and  auscultation  must  sometimes 
wait  upon,  as  in  the  relation  of  the  vocal  fremitus  to  differential 
diagnosis. 

On  account  of  the  ease  and  simplicity  with  which  palpation  may 
be  performed,  beginners  are  prone  to  neglect  its  careful  cultivation. 
This  is  a  mistake.  The  tactile  sense  cannot  be  practised  too  much 
or  too  precisely.  It  often  happens  that,  for  various  reasons,  as  of 
prostration  and  exhaustion,  or  of  delicacy  of  feeling  on  the  part  of 
the  patient,  inspection  cannot  be  satisfactorily  done,  whereupon  larger 
dependence  must  be  placed  on  palpation  for  ascertaining  the  general 
results  of  the  former  method. 

GENERAL  METHOD  OF  PALPATION 

As  in  inspection,  the  chest  should  be  entirely  or  sufficiently  bared 
so  as  to  make  the  direct  and  comparative  investigation  of  every  region 
as  definite  as  possible.  Occasionally  the  hand  may  be  slipped  beneath 
the  gauze  underwear.  The  posture  of  the  patient  should  be  in  a 
manner  both  even  and  easy,  whether  standing,  sitting,  or  lying,  avoid- 
ing especially  asymmetries  of  contour  due  to  a  shrugged  shoulder, 
turned  neck,  or  improperly  placed  hands  and  arms. 

Before  applying  the  hands,  the  examiner  should  see  that  their 
palmar  surfaces  are  warm  and  dry,  and  the  nails  as  short  as  the 

63 


64 

fleshy  finger  tips;  and  the  hands  first,  then  the  finger  tips,  if  need  be 
for  more  accurate  localization,  may  be  employed  by  applying  them 
gently  and  flatly,  but  firmly,  upon  the  parts  to  be  palpated ;  cold, 
clammy  hands,  sharp,  scratchy  finger  nails,  and  an  abrupt,  rough,  or 
poking  pressure  are  not  only  objectionable  to  the  patient,  but  by  the 
more  or  less  nervous  apprehensiveness  or  resentful  resistance  of  the 
patient  cause  incoordination  of  movements  and  reflex  or  voluntary 
rigidities  that  seriously  interfere  with  the  reliability  of  the  physical 
signs.  Always,  corresponding  regions  on  the  two  sides  are  to  be 
palpated  by  a  simultaneous  application  of  both  hands,  or  by  applying 
one  hand  similarly  on  both  sides,  or  by  alternately  pressing  with  each 
hand  on  its  respective  side.  Thus,  the  infraclavicular,  axillary,  and 
infrascapular  regions,  for  example,  are  studied  comparatively  in 
each  case. 

PALPATION    OF    CERTAIN    INSPECTED    SIGNS 

As  regards  the  general  and  unilateral  abnormalities  of  size,  shape, 
and  symmetry  of  the  chest,  palpation  is  hardly  useful  as  an  adjunct 
to  inspection;  but  in  ascertaining  the  presence  and  characteristics  of 
local  deformities,  and  also  of  local  alterations  of  movement,  this 
method  is  of  considerable  practical  value. 

Thus,  palpation  gives  exactitude  to  the  observations  of  bony  promi- 
nences, supraclavicular  depressions,  intercostal  widenings,  etc.,  for 
example. 

Again,  important  aid  is  derived  from  palpation  in  the  perception 
of  local  asymmetries  of  movement.  The  infraclavicular  regions  are 
usually  first  examined  by  placing  both  hands  there,  the  finger  tips 
resting  in  the  first  intercostal  spaces  and  pointing  a  little  outward,  so 
that  the  hands  form  a  V-shape.  The  axillary  regions  may  be  pal- 
pated standing  either  in  front  of  or  behind  the  patient;  likewise  with 
the  infrascapular  regions,  although,  when  standing  behind,  the  patient 
should  bend  forward  so  as  to  permit  the  examiner  to  apply  the  hands 
vertically  and  avoid  the  dubious  results  of  an  otherwise  constrained 
position  of  the  wrists. 

Owing  to  the  frequency  with  which  that  most  prevalent  and  grave 
pulmonary  disease — tuberculosis — attacks  the  apices  of  the  lungs, 
especial  care  is  needed  in  acquiring  the  best  procedure  and  most 
delicate  skill  in  the  palpation  of  the  supraclavicular  and  supraspinous 
regions  of  the  thorax,  in  order  that  the  early  evidences  of  the  disease 
may  be  detected,  since  upon  these  do  the  prognosis  and  prompt  and 


PALPATIOX  65 

rational  treatment  depend.  Standing  in  front  of  the  patient,  who 
may  be  seated,  two  or  three  finger  tips  are  allowed  to  rest  in  the 
supraclavicular  spaces,  with  the  fingers  gently  curved  very  much  after 
the  manner  of  a  pianist  or  typewriter.  A  little  more  flatly  applied 
behind  the  anterior  borders  of  the  trapezius  muscles,  the  fingers  may 
here  also  discover  one-sided  abnormal  movement.  The  detection  here 
of  delayed  and  diminished  movement,  "  expiratory  drag,"  or  "  lag- 
ging "  breathing,  is  strong  evidence  presumptive  and  particular  of  the 
deficient  expansion  of  pulmonary  vesicles  associated  with  incipient 
tuberculosis.  Lagging,  or  less  and  later  movement  over  the  lower 
part  of  one  side  is  usually  indicative  of  pleuritis  or  pneumonitis, 
possibly  of  infarction  or  of  pleurodynia  on  that  side. 

The  freedom,  extent,  and  symmetry  of  diaphragmatic  movements 
may  also  be  palpated  by  applying  the  hands  (finger  tips)  over  the 
epigastrium;  the  irregular,  restricted,  and  one-sided  movements  of 
diaphragmatic  pleuritis,  phrenic  nerve  palsies,  and  local  peritonitis, 
may  thus  be  felt.  Finally,  palpation  may  be  employed  to  aid  inspec- 
tion in  noting  the  frequency  and  rhythm  of  the  respiratory  excursions. 


THORACIC    VIBRATIONS:    VOCAL    FREMITUS 

NORMAL 

When  the  hand  is  laid  upon  the  chest  of  a  healthy  person  while 
speaking,  a  fine,  vibratory,  tremor-like  sensation,  or  whizzing,  is  felt. 
This  voice  vibration  or  resonant  thrill  is  called  the  vocal  fremitus  or 
tactile  fremitus,  less  commonly  the  pectoral  fremitus.  The  sound 
vibrations  of  normal  breathing,  or  the  vesicular  respiratory  murmur 
as  it  is  called,  are  appreciable  only  by  the  ear  and  not  by  the  hands. 

The  method  of  examining  the  vocal  fremitus  is  to  have  the  patient 
utter  certain  words  in  distinct,  even,  measured  monotones  while  the 
examiner's  hands  are  applied  upon  different  regions  of  the  chest  in 
a  comparative  manner.  The  old  way  is  to  ask  the  patient  to  repeat 
the  count,  "  one,  two,  three."  As  the  normal  vocal  vibration  is  deli- 
cate under  all  circumstances,  and  for  this  reason  is  easily  deadened 
by  too  forcible  pressure  of  the  hand,  it  is  more  effective  to  have  the 
patient  use  the  words  "  ninety-nine,"  or  such  artificially  phrased  terms 
as  "  nom-nom-nom,"  by  which  the  predominance  of  the  nasal  conso- 
nants adds  resonance  to  the  tones.  To  determine  the  finer  vibrations, 
it  is  advisable  to  employ  the  tips  of  the  first,  second,  and  third  fingers 

instead  of  the  whole  hand. 

7 


66  PHYSICAL   DIAGNOSIS 

Besides  the  simple  factors  of  the  strength  of  the  voice — i.  e.,  its 
loudness,  coarseness,  and  graveness — the  intensity  of  the  vocal  fremi- 
tus  depends  upon  several  other  physical  conditions,  as  follows:  (a) 
On  the  pitch  of  the  voice:  the  lower  the  pitch  the  more  marked  the 
fremitus,  and  vice  versa.  This  explains  why  the  vibrations  are  usually 
more  distinctly  felt  in  adults  than  in  children,  and  in  males  than 
in  females.  Furthermore,  just  as  in  musical  (stringed)  instruments 
the  vibrations  of  the  lower  strings  are  much  more  perceptible  than 
those  of  the  upper  strings,  being  of  greater  amplitude  and  fewer  in 
number  in  a  given  time,  so  the  fremitus  of  the  singing  or  speaking 
voice  in  the  bass,  baritone,  or  contralto  register  is  more  marked  than 
in  the  tenor  or  soprano,  and  accompanies  the  lower  notes  of  any 
given  register  more  than  the  upper;  the  thin,  high-pitched,  "  throaty  " 
notes  are  without  fremitus.  (I)  On  the  size  or  diameter  of  the  bron- 
chus conducting  the  vocal  vibrations,  and  its  nearness  to  Hie  chest  trail. 
Hence  the  fremitus  is  more  marked  on  the  right  side  because  of  the 
larger,  more  superficial  right  bronchus,  (c)  The  thickness  of  the 
chest  wall:  the  thicker  the  chest  the  feebler  the  fremitus.  The  voice 
vibrations  are  much  diminished  or  lost  in  passing  from  the  elastic, 
air-containing  lung  tissue  to  the  denser,  more  resistant  muscle  and 
fat.  (d)  The  distance  of  the  part  under  examination  from  the  larynx: 
the  greater  the  distance  the  weaker  the  fremitus.  Therefore,  the 
fremitus  is  more  marked  over  the  upper  anterior  aspect  of  the  chest 
than  over  the  axillary  and  infrascapular  regions. 

Normal  Variations. — Because  of  the  preceding  physical  and  ana- 
tomical conditions,  each  individual  will  have  his  own  degree  of  vocal 
fremitus  or  personal  standard  of  normal  fremitus,  with  regional  vari- 
ations dependent  upon  similar  conditions.  The  relative  intensities 
of  fremitus  due  to  these  normal  variations  should  be  carefully  noted, 
so  that  apparent  exaggerations  and  diminutions  of  the  fremitus  are 
not  erroneously  considered  pathological. 

Normal  right-sided  increase  of  the  vocal  fremitus  is  the  most  im- 
portant practical  point  to  be  borne  in  mind  in  this  respect.  This 
difference  over  the  apices  of  the  two  lungs  requires  careful  considera- 
tion in  the  diagnosis  of  beginning  tuberculosis,  because  of  the  fre- 
quency of  its  occurrence  here.  This  relative  increase  of  the  fremitus 
on  the  right  side  is  explained  by  the  slightly  more  massive  and  denser 
right  lung,  perhaps  because  of  the  firm,  resisting  liver  beneath  it, 
and  by  the  additional  fact  of  the  anatomic  relations  of  the  right 
bronchus.  Its  largeness  of  lumen,  shortness,  and  its  leaving  the 
trachea  with  such  directness  as  the  slightly  acute  angle  gives  it,  permit 


PALPATIOX  67 

greater  force  of  vibrations  to  enter  the  right  lung,  and  so  transmit 
more  sensation  through  the  chest  wall. 

This  slight  physiologic  increase  of  the  vocal  fremitus  on  the  right 
side,  as  compared  with  the  left,  region  for  region,  must  constantly 
be  borne  in  mind  to  avoid  inferring  a  pathologic  thickening  of  the 
lung  on  that  side,  or,  on  the  other  hand,  some  pleuritic  encroachment 
upon  the  lung  on  the  left  side,  because  of  the  relatively  diminished 
fremitus  there. 

Vice  versa,  the  discovery  of  areas  of  diminished  vocal  fremitus  on 
the  right  side,  or  of  increased  fremitus  on  the  left,  is  naturally  easier 
because  of  this  normal  difference  noted  just  before,  and  all  the  more 
significant  of  morbid  physical  changes. 

The  borders  of  the  lungs  may  be  mapped  out  by  the  tactile  fremi- 
tus in  adults  with  strong,  low-pitched  monotones  of  the  voice,  espe- 
cially the  lower  borders;  the  cessation  of  the  fremitus  as  one  reaches 
the  liver  on  the  right  side  is  promptly  ascertained. 

Normal  regional  differences  in  the  intensity  of  the  fremitus,  be- 
cause of  distances  from  the  larynx,  and  variations  in  the  thickness 
of  the  chest  wall  must  also  be  allowed  for.  Therefore,  the  fremitus 
is  more  marked  over  the  upper  and  anterior  than  the  lower  and  pos- 
terior portions  of  the  chest,  being  especially  noticeable  at  the  sternal 
halves  of  the  infraclavicular  regions  and  the  interscapular  regions. 
It  is  moderately  felt  at  the  axillary  and  infrascapular  regions;  but, 
owing  to  the  thickness  of  the  chest  covering  being  greater  on  account 
of  muscle,  mammary  gland,  fat,  and  bone,  the  fremitus  is  considerably 
weakened  at  the  mammary  and  scapular  regions. 

Moreover,  in  persons  with  thin-walled  chests  the  fremitus  is  rela- 
tively much  more  perceptible  in  general,  region  for  region,  than 
where  a  large  amount  of  dense  tissue  intervenes  between  the  lungs  and 
the  palpating  hands. 

PATHOLOGIC 

Pathologically,  the  vocal  fremitus  may  be  increased,  diminished, 
or  absent. 

Increased  Vocal  Fremitus. — Generally  speaking,  all  firm  infiltra- 
tions of  lung  tissue  cause  increased  fremitus,  obeying  the  physical 
law  that  sound  vibrations  are  conducted  with  greater  intensity  through 
solids  than  through  air.  Hence,  bearing  in  mind  the  normal  variations 
already  noted,  and  estimating  their  relative  prominence  by  a  general 
survey  in  each  individual  examined,  we  proceed  to  localize  any  area 
or  areas  in  which  the  fremitus  is  abnormally  marked;  the  detection 


68  PHYSICAL    DIAGNOSIS 

of  such   indicates  the  presence  underneath  of   consolidation  of   the 
spongy  or  vesicular  lung  tissue  usually. 

Consolidation  of  the  lung  tissue  as  a  cause  of  marked  vocal  fremi- 
tus  is  best  exemplified  in  lobar  pneumonitis  (pneumonia)  ;  in  pul- 
monary tuberculosis  it  is  commonly  perceived  over  the  solidified  areas. 
In  instances  of  the  former  the  fremitus  is  usually  felt  posteriorly  below 
the  scapula,  and  over  a  larger  area  than  the  latter,  which  also  occurs 
most  frequently  at  the  apices  of  the  lungs,  and  anteriorly.  In  rare 
cases  of  so-called  massive  pneumonia,  in  which  the  bronchial  tubes 
are  plugged  with  exudate,  the  voice  is  feebly,  or  not  at  all,  trans- 
mitted through  the  solidified  lung.  In  the  later  stages  of  tuberculosis, 
if  the  pulmonary  cavities  are  large,  superficial,  and  dense-walled,  the 
tactile  fremitus  may  be  increased  (good  conduction  and  consonance 
by  reflection  of  the  vibrations  from  the  walls).  Increased  fremitus 
is  also  felt  (above  a  pleuritic  effusion,^  the  lung  being  compressed 
against  the  thoracic  wall,  particularly  in  the  infraclavicular  region; 
over  fibroid  thickening/hemorrhagic  infarction  (pulmonary  apoplexy), 
and  edema  of  the  lung  (moderately);  over ''solid  tumors  lying  in 
contact  with  and  between  a  large  bronchus  and  the  chest  wall,  or,  at 
times,  even  a  large  band  of  pleuritic  adhesion  stretched  between  the 
lung  and  the  costal  pleura ;  lastly,  in  some  cases  of  chronic  bronchitis 
with  marked  dilation  of  the  bronchial  tubes  and  adjacent  consolida- 
tion, these  conditions  are  indicated  by  the  increased  fremitus. 
(  Diminished  Vocal  Fremitus. — In  the  majority  of  instances,  abnor- 
mally weak  pectoral  fremitus  points  to  the  intervention  of  something 
between  the  lung  and  chest  wall  that  interferes  with  the  conduction 
of  the  voice  vibrations  to  the  surface.  Thus, 'a  thickened  pleura,  or 
thin  layers  of  an  acute  or  subacute  pleuritis,  so  diminish  the  fremitus. 
Again,  since  the  bronchial  tubes  are  the  most  important  direct  means 
of  voice  transmission,  diminution  of  their  caliber,  as  from  bronchitis, 
asthma,  stenosis,  or  tumor  compression  may  lessen  the  sign.  *  Cavities 
in  the  lung  that  have  become  partly  filled  with  liquid  exudate  mani- 
fest a  change  from  increased  to  diminished  fremitus. 

As  the  degree  of  fremitus  over  vesicular  lung  tissue  depends  in 
part  upon  its  tension,  we  sometimes  find  it  impaired  in  marked  em- 
physema, owing  to  the  loss  of  elasticity,  in  spite  of  the  fact  that  the 
alveoli  are  enlarged.  But  here  the  partial  occlusion  of  many  of  the 
bronchioles  in  this  disease  also  operates  simultaneously  to  produce 
the  same  result.  In  so-called  compensatory  emphysema  or  temporarily 
exaggerated  lung  action,  the  tension  being  increased  and  the  whole 
respiratory  tract  open  and  distended  on  that  side,  the  fremitus  is 


PALPATIOX  69 

increased  at  first,  and,  as  recovery  of  the  diseased  side  removes  the 
reason  for  its  continuance,  later  dintini*Iu.'s  to  normal. 

It  should  not  be  forgotten  that  diminished  vocal  fremitus  is  not 
pathologically  significant  unless  the  voice  is  strong  enough  and  the 
thoracic  walls  thin  enough;  feeble  voice  and  dense,  fat-laden  walls 
are  in  themselves  sufficient  causes  for  weak  fremitus,  and  then  this 
is  evident  on  both  sides,  although  not  unusually  bilateral  in  emphy- 
sema, also. 

Absent  Vocal  Fremitus.  —  Bronchial,  pleural,  and  mural  condi- 
tions may  cause  total  abolition  of  fremitus. 

In  occlusion  of  a  bronchus  there  is  total  absence  of  the  fremitus 
over  the  area  supplied  by  the  occluded  bronchus,  as  the  oscillations 
of  the  voice  are  then  entirely  checked  from  entering  that  portion  of 
the  lung.  The  principal  causes  of  closure  of  the  bronchial  tubes  are 
the  pressure  of  a  large  aneurism,  mediastinal  tumor,  or  enlarged 
glands;  fibrinous  bronchitis,  blocking  accumulations  of  mucus,  and 
foreign  bodies  within  the  lumen. 

Pleural.  effusions  are  the  most  frequent  causes  of  absent  vocal 
fremitus.  Whether  liquid  or  air,  their  presence  in  the  pleural  cavity 
interferes  with  the  conduction  of  the  vibrations  to  the  chest  wall,  the 
denser  medium  of  the  latter  inhibits  their  already  weakened  intensity, 
and  the  partially  or  completely  collapsed  lung,  having  lost  its  elastic 
tension,  also  fails  to  vibrate.  Ordinarily,  the  encroaching  fluid  is 
either  serofibrinous  or  purulent  from  inflammatory  or  tuberculous 
exudation;  it  may  be  a  dropsical  transudation  (hydro  thorax),  or  it 
may  be  partly  (serosanguinolent)  or  wholly  blood  (hemo  thorax)  or 
air  (pneumothorax).  A  greatly  thickened  pleura  will  also  suppress 
palpable  voice  transmission. 

The  palpation  of  the  vocal  fremitus  is  of  the  most  practical  value 
in  the  differential  diagnosis  of  pleuritis  and  pneumonitis,  diminution 
of  the  thrill  or  its  absence,  especially  in  the  lower  and  posterior 
part  of  the  thorax,  being  a  cogent  indication  of  the  presence  of  the 
former  affection. 

It  is  needless  to  more  than  mention  the  deadening  effect  upon 
the  tactile  fremitus  that  various  thickenings  of  the  chest  wall  have, 
such  as  tumors,  abscess,  edema,  and  the  like. 

Pleural  or  Friction  Fremitus.  —  Normally,  the  costal  and  pulmonary 
layers  of  the  pleura?  glide  smoothly  over  each  other,  so  that  no  fric- 
tional  vibration  is  perceptible  to  the.  hand.  When,  however,  the  pleural 
surfaces  become  inflamed,  and  roughened  and  thickened  by  a  sticky 
or  buttery  fibrinous  exudate,  the  friction  produced  by  the  respiratory 


>-,  A 


SL*L+rt*~***- 

" 


70  PHYSICAL   DIAGNOSIS 

rub  gives  rise  to  a  palpable  sensation  to  the  examiner's  hand.     This  is 
variously  described — often  according  to  the  intensity  of  the  inflamma- 
tion or  of  the  respiratory  energy — as  of  the  lightest  grazing  or  scratch-*^ 
ing  or  scraping  character,  or  it  may  be  of  a  dull,  grating,  or  creaking  ^ 
character,  like  the  bending  of  new  leather.     In  some  cases  of  the  . 
grating  fremitus,  the  quick  succession  of  jerky,  detached  sensations' 
is  due  to  the  fact  that  "  even  in  circumscribed  areas  tbe  roughened  3 
pleura?  do  not  touch  each  other  at  all  points  at  the  same  time";  in  "^ 
others,  it  is  due  to  the  irregular  roughnesses  of  plates  of  calcareous^  / 
infiltration  in  the  pleura  of  very  old  chronic  thickening  and  adhesions.^ 
The  friction  fremitus  is  best  felt    (and  heard)    in  the  axillary  ss 
regions,  about  the  fifth  and  sixth  intercostal  spaces,  but  also  a  little* 
to  the  front  and  below  the  scapular  angle.    It  may  have  a  to-and-fro' 
quality,  synchronous  with  the  respiratory  rhythm,  or  it  may  be  felt 
only  with  inspiration,  near  the  end.     Deep  inspiration  usually  in- 
creases the  rub,  although  after  a  number  of  such  inspirations  theT 
grazing  surfaces  may  become  smoothed  out  and  the  fremitus  dis-« 

i  appear;  firm  pressure  with  the  hand  apposing  the  inflamed  pleural 
layers  more  closely,  may  also  temporarily  exaggerate  the  sensation., 
^  v   Not  infrequently  the  patient  feels  the  friction  as  well  as  the  pain 
caused  by  it,  and  is  able  to  indicate  the  exact  seat  of  the  trouble.       .» 
The  disappearance  of  pleural  fremitus,  besides  reduction  by  respi-  ^ 
ratory  smoothing  action  and  the  absorption  of  recovery,  may  be  due  __ ' 
to  the  separating  effect  of  a  progressing  liquid  effusion — tbe  dry  or 
plastic  pleuritis  becoming  serofibrinous — or  to  the  formation  of  adbe-  ^ 
Visions  between  the  parietal  and  visceral  pleura. 

^i         Bronchial  or  Rhonchal  Fremitus. — This  is  a  coarse  or  fine  rattling 
•x  sensation  which  may  be  felt  all  over  the  chest,  especially  in  children, 
i-  in  diffuse  catarrhal  bronchitis.     The  vibrations  are  synchronous  with 
J"~the  movements  of  respiration,  although  usually  more  distinct  with 
«3   inspiration,  except  in  asthmatic  cases.     They  are  produced  by  viscid 
>  ^  j*  mucus   or  abundant  liquid  exudation   partially   plugging   or  filling 
|<4U^  congested  or  inflamed  bronchial  tubes,  disturbed  by  the  ingoing  and 
outgoing  currents  of  air.     As  this  agitation  of  bronchial  secretion 
.gives  rise  to  the  audible  rales  (see  under  Auscultation)  or  rhonchi — 
variously  pitched  snoring,  whistling,  or  bubbling  sounds — when  pal- 
pated the  resulting  vibrations  are  often  designated  as  rhonchal  fremi- 
tus.    It  is  better  elicited  by  getting  the  patient  to  take  several  deep 
^inspirations,  and  is  more  generally  perceptible  over  the  whole  chest 
i  i  in  children  than  in  adults.    In  the  latter,  bronchial  fremitus  is  usually 
due  to  a  rather  widespread  chronic  bronchitis  associated  with  asthma 


« 


PALP  ATI  OX  71 

or  emphysema,  and  not  rarely  with  dilation  of  one  or  more  portions 
of  the  larger  bronchi  (bronchiectasis) ,  the  discovery  of  which  may 
be  facilitated  by  noticing  a  more  decided  fremitus  over  that  region 
because  of  the  more  sonorous  gurgling  in  such  a  formation.  This 
leads  to  the  related  subject  of : 

Cavernous  fremitus,  which  is  simply  that  felt  over  superficial 
cavities  of  the  lung  when  near  the  apex,  and  in  those  whose  chests 
are  thin-walled  and  emaciated.  The  vibrations  are  distinctly  local- 
ized, fine,  and  may  disappear  after  a  spell  of  coughing. 

Bronchial  fremitus  may  be  differentiated  from  pleural  fremitus 
by  the  following  points :  (a)  Location. — The  former  is  more  diffused, 
the  latter  unilateral;  and  when  the  fremitus  is  circumscribed,  its 
occurrence  over  the  upper  and  anterior  portions  of  the  lung  indi- 
cates a  bronchial  origin,  the  pleural  being  lower,  and  either  axillary 
or  posterior,  (b)  Character. — Bronchial  fremitus  is  more  continu- 
ous, pleural  more  jerky  and  interrupted,  (c)  Rhythm. — Bronchial 
is  felt  almost  as  constantly  during  inspiration  as  during  expiration, 
while  the  pleural  is  more  apparent  at  the  end  of  inspiration  or  the 
beginning  of  expiration,  (d)  Behavior  in  Coughing. — Cough  accom- 
panied with  free  spitting  diminishes  bronchial  palpable  rales ;  without 
such  looseness  they  become  weaker  at  some  points  and  present  or 
exaggerated  at  others,  on  account  of  displacement  of  the  mucus; 
pleural  fremitus  is  not  so  modified  by  cough. 

Tussive  Fremitus. — This  means  the  palpable  vibrations  transmitted 
to  the  chest  wall  by  the  act  of  coughing  in  itself.  It  is  of  very  little 
clinical  importance  except  in  cases  of  aphonia,  when  it  may  serve  to 
indicate  physical  changes  otherwise  determinable  by  the  vocal  fremi- 
tus, increase,  diminution,  and  absence  of  the  latter  constituting  a 
superior  means  of  ascertaining  the  changes  similarly  affecting  the 
tussive  fremitus  under  usual  conditions. 

**  i~  Succussion,  or  Splashing  Fremitus. — When  sensation  of  a  splash- 
ing  wave  against  the  thoracic  wall  is  felt  with  the  shaking  of  the 
body,  it  signifies  the  presence  of  air  and  liquid  in  the  pleural  sac 
(hydropneumothorax ;  pyopneumothorax) . 

Fluctuation. — Simple  fluctuation,  as  elicited  by  surgeons  in  the 
detection  of  superficial  abscesses  and  cysts  by  an  alternating  method 
of  finger  pressures,  may  be  perceived  in  cases  of  pleural  effusion 
where  the  intercostal  spaces  bulge,  as  from  an  empyema.  The  so- 
called  " peripheric  fluctuation"  (Tarral)  is  elicited  by  "giving  a 
quick,  sharp  fillip  in  an  intercostal  space,  perpendicular  to  the  sur- 
face, when  a  sensation  of  fluctuation  will  be  transmitted  to  a  finger 


72  PHYSICAL    DIAGNOSIS 

of  the  other  hand  firmly  applied  to  the  surface  in  the  same  space,  at 
a  short  distance  from  the  point  percussed."  While  this  may  deter- 
mine the  presence  of  a  tense  pleural  effusion,  it  is  particularly  applica- 
ble in  the  detection  of  a  hydropneumothorax.  A  thickened  pleura 
would  interfere  with  the  manifestation  of  this  sign. 

Resistance. — The  presence  of  pulmonary  or  pleural  tumors  may 
sometimes  he  localized  by  an  increased  sense  of  resistance  over  the 
growths,  especially  where  the  ribs  and  interspaces  may  be  bulged; 
their  hard  or  soft  consistence  may  indicate  the  carcinomatous  or 
sarcomatous  characteristics. 

Likewise,  occasionally  the  diagnosis  of  a  pneumonic  consolidation 
may  be  aided  by  a  relative  increase  of  resistance  to  the  palpating 
ringer,  elicited  over  the  corresponding  interspaces,  provided  the  lung 
is  closely  apposed  to  the  chest  wall.  The  tension  of  a  large  pleural 
effusion  is  still  more  evident. 

Again,  a  limited  area  of  pitting  with  finger  pressure  slowly  and 
firmly  applied,  with  marking  of  the  cutaneous  furrows,  and  a  con- 
sistence not  unlike  that  of  dough  or  putty,  usually  points  to  a  pleural 
collection  of  pus.  This  occurs  at  the  base  of  the  chest,  and  is  accom- 
panied with  slight  swelling  and  inflammatory  redness  and  tenderness. 

Pulsation. — Palpation  confirms  the  ocular  detection  of  pulsations 
abnormally  located.  Thus  is  recognized  the  pulsating  empyema.  The 
heart  being  displaced  to  the  right,  in  certain  rare  cases  marked  pulsa- 
tion has  been  felt  at  the  sternal  portion  of  the  infraclavicular  and 
mammary  regions;  sometimes  pulsations  are  found  even  on  the  left 
lower  portion  of  the  thorax,  and  here  are  less  likely  to  be  mistaken 
for  aneurismal  pulsations.  A  pulsatile  movement  of  the  lung  has 
been  noticed  in  some  rare  instances  of  pneumonitis  and  intrathoracic 
cancer. 


CHAPTER    IV 
PERCUSSION 

Fundamental  Principle. — It  is  that  in  common  daily  life  we 
learn  to  distinguish  many  objects  by  the  different  sounds  they  emit 
when  struck;  such  physical  conditions  as  their  material  quality,  den- 
sity, thickness,  partial  or  complete  hollowness,  are  so  recognized. 
This  principle  is  applied  to  the  physical  diagnosis  of  the  human  body ; 
organs  are  located,  their  size,  shape,  and  outline  mapped  out  or  care- 
fully inferred,  and  such  properties  as  mentioned  before  determined 
in  their  normal  and  abnormal  relations  and  variations  and  sig- 
nificances. 

The  fact  that  with  this  method  of  examination  began  in  reality 
modern  scientific  diagnosis,  deserves  a  brief  look  backward,  as  an 
introduction  to  present  procedure. 

Historical  Note. — We  owe  to  the  Viennese  physician,  Auenbrugger, 
the  discovery  of  the  method  of  percussion,  as  described  in  his 
memorable  work  entitled  Inventum  novum  ex  percussions  thoracis 
Innnani,  etc.,  which  appeared  in  1761.  The  importance  and  practical 
value  of  the  method,  being  disputed  and  ridiculed  into  neglect,  failed 
of  any  recognition  for  nearly  fifty  years,  when  Corvisart,  body-physi- 
cian to  Napoleon  I,  in  1808  gave  it  substantial  impetus  by  reviving 
and  commending  its  use  and  improving  its  application.  His  French 
translation  soon  led  Piorry  to  develop  further  the  method  into  the 
topographical  percussion,  and,  in  1828,  to  the  invention  of  the  plexim- 
eter.  Since  then,  through  the  wider  observations  and  deeper  under- 
standings of  such  men  as  Skoda,  Wintrich,  Traube,  Gerhardt,  Weil, 
Walshe,  Sansom,  and  Flint,  chest  percussion  has  been  elaborated  into 
a  procedure  as  precise  as  auscultation,  very  often  and  usually  quite 
as  delicate  and  difficult  to  practise.  Most  important  advances  in  the 
percutory  practise  and  interpretation  were  initiated  by  Piorry  and 
Skoda;  the  introduction  and  development  of  mediate  palpatory  per- 
cussion (see  p.  84)  in  the  examination  of  the  abdominal  as  well  as 
the  thoracic  organs  being  especially  noteworthy  of  the  former;  the 

73 


74  PHYSICAL    DIAGNOSIS 

latter's  discovery  of  the  physical  causes  of  many  of  the  qualities  of 
percussion  sounds  and  their  normal  and  pathologic  connections,  and 
his  exhaustive  contributions  to  the  subject  of  tympanicity  (1839) 
were  of  distinguished  importance. 

Definition. — Percussion  is  the  practise  of  striking  or  tapping  the 
body  to  elicit  vibrations,  to  obtain  information  as  to  the  physical 
condition  of  the  underlying  organs.  It  probably  requires  more  perse- 
verance in  acquiring  manipulative  skill  than  any  other  method  of 
physical  examination.  Such  facility  is  requisite  not  only  to  bring 
out  the  true  and  characteristic  sounds,  but  also  to  allow  the  attention 
of  listening  to  be  concentrated  upon  those  sounds  which  it  is  the 
purpose  of  the  method  to  study.  The  mind  of  the  examiner  must  be 
freely  receptive  and  intelligently  alert,  and  not  diverted  by  the  con- 
scious and  zealous  energy  of  awkward  and  laborious  manual  effort. 
To  this  end  the  student  needs  incessant  practise,  assiduously  at  the 
outset,  so  that  his  technic  becomes  a  matter  of  automatism,  almost, 
along  the  lines  given  in  the  details  of  method  to  follow. 

METHODS    OF    PERCUSSION 

There  are  two  methods  of  percussion,  immediate  or  direct,  and 
mediate  or  indirect. 

Immediate  percussion,  by  which  striking  of  the  chest  is  performed 
directly  with  the  tips  of  the  fingers  (usually  the  second  finger),  or 
even  with  the  flat  of  the  hands,  was  the  method  employed  by  Auen- 
brugger  and  his  early  followers.  It  is  seldom  used  now,  not  only 
because  of  the  annoyance  to  the  patient,  but  because  of  the  more 
agreeable  and,  so  far  as  results  are  concerned,  greatly  superior  me- 
diate method  invented  by  Piorry.  Nevertheless,  there  are  circum- 
stances in  which  this  method  may  be  resorted  to  with  advantage. 
Thus,  where  there  are  extensive  and  marked  differences  between  the 
two  sides  of  the  chest,  a  rapid  tapping  or  lightly  slapping  with  the 
palmar  surfaces  of  the  hands  will  often  elicit  quite  satisfactorily  the 
distinctive  sounds,  as  of  the  presence  of  a  pleuritic  effusion.  The 
clearer,  more  resonant  tone  over  the  upper  part  of  the  chest,  shading 
abruptly  into  the  duller  note  at  the  edge  of  and  over  the  cardiac  and 
hepatic  regions,  enables  one  to  delimit  the  lung-heart  and  lung-liver 
boundaries  in  thin  individuals  fairly  well.  Furthermore,  the  fact 
that  the  sounds  thus  produced  are  virtually  vibrations  communicated 
by  the  bones  of  the  thorax,  points  to  the  added  value  occasionally  of 
directly  tapping  the  clavicles,  ribs,  sternum,  and  scapulae;  lightly 


PERCUSSION  75 

percussing  the  clavicles  not  infrequently  indicates  the  presence  of 
subjacent  tubercular  infiltration,  as  I  have  demonstrated;  enlarge- 
ments of  the  heart,  aortic  aneurism,  large  effusions,  and  mediastinal 
tumors  may  also  encroach  under  the  sternum  so  as  to  be  inferable 
from  the  results  of  immediate  percussion.  The  direct  percussion 
of  the  softer  parts,  as  the  intercostal  spaces,  does  not  yield  so  clear 
and  recognizable  tones. 

Mediate  percussion  may  be  practised  in  three  different  ways,  as 
follows:  (1)  Finger  percussion;  (2)  finger-pleximeter  percussion; 
(3)  hammer-pleximeter  percussion.  That  is,  the  interposed  medium 
— the  thing  applied  on  the  chest  to  receive  the  stroke — may  be  either 
a  finger  or  a  pleximeter  made  of  some  solid  material,  conveniently 
shaped  for  the  purpose;  and  the  striker,  or  plexor,  may  be  either  a 
finger  or  special  hammer.  Each  of  the  three  modes  may  yield  satis- 
factory results  if  applied  with  respective  skill  and  care,  and  when 
such  proficiency  is  acquired  it  is  wise  to  stick  to  the  particular  mode 
throughout  one's  work,  although  it  may  be  said  that  facility  in  the 
list'  of  the  simple  finger  method  of  percussion  makes  it  much  easier 
to  apply  the  others  than  vice  versa.  To  change  methods  and  instru- 
ments frequently  tends  to  mediocrity  in  the  use  of  all  of  them. 

The  "  clinical  supremacy  "  of  the  fingers  as  plexor  and  pleximeter 
lies  in  the  fact  that  they  are,  in  the  first  place,  naturally  the  most 
handy;  instruments  artificially  made  are  apt  to  be  inconveniently 
misplaced,  lost,  or  forgotten.  Secondly,  fingers,  with  their  sense- 
organs  in  close  contact  with  the  region  percussed,  afford  more  delicate 
and  intelligent  results  than  lifeless  appliances;  especially  valuable  in 
this  connection  is  the  appreciation  of  the  degree  of  the  sense  of 
resistance  while  percussing,  to  be  referred  to  more  fully  later.  Third- 
ly, the  pleximeter  finger  is  adapted  readily  to  accurate  fitting  on  the 
thoracic  surface,  excepting  at  times  the  supraclavicular  fossa.  Finally, 
the  homogeneity  of  flesh  and  bone  against  like  structure  of  the  thorax 
avoids  the  confusion  of  the  percussion  note  of  the  underlying  organ 
with  the  clacking  sound  obtained  by  striking  a  hard-rubber  plexim- 
eter, for  example. 

Pleximeters  consist  of  small  plates  or  upright  pieces  of  gutta- 
percha,  ivory,  glass,  or  wood,  round,  oblong,  or  elliptical  in  shape,  so 
as  to  be  applied  to  the  intercostal  spaces.  The  pleximeter  invented 
by  Piorry  was  a  thin,  circular,  or  oval  plate  of  ivory  about  2  or  2£ 
cm.  wide,  fitted  at  opposite  points  with  two  vertical  ears  roughened 
on  their  outer  aspects,  and  just  large  enough  to  permit  the  thumb 
and  finger  to  hold  it  steadily  and  apply  it  evenly  and  firmly  to  the 


76  PHYSICAL    DIAGNOSIS 

surface.     Sansom's  pleximeter,  a  combination  of  hard-rubber  pillar, 
and  plates  of  unequal  size,  is  very  useful  in  percussing  over  small 
depressions,  as  above  the  clavicles,  the  only  re- 
gion where  finger  percussion  may  sometimes  be 
difficult.     For  the  same  purpose  the  double  plex- 
imeter of  Seitz,  like  a  small  tongue  spatula  with 
a  double  curve,  will  occasionally  be  found  con- 
venient.    As  helpful  as  any  is  a  cylindrical  piece 
of    india-rubber,    about    the    diameter    and   two- 
FIG.   is.  -  SANSOM'S    ^^  the  j       th  of  a  Httle  fi          pierced  length- 

I  i .  i  \  i  M  !  i  i  i .' .     (^  1  y~* 

son.)  wise   with   strong  wire,   the   ends  of   which   are 

twisted  together  to  form  a  handle,  after  extend- 
ing a  short  vertical  distance  above  the  rubber,  and  then  bent  at  right 
angles. 

The  percussion  hammer  was  invented  by  Wintrich  in  1841.     It 
is  generally  of  moderate  weight,  has  a  firm  but  light  handle  of  wood 
or  aluminium  fixed  to  a  heavier  metal  head  tipped 
with  rubber,  or  ending  in  a  ring  containing  a  cylin- 
drical piece  of  india-rubber. 

Technic  of  Mediate  Percussion. —  (1)  FINGER 
PERCUSSION. — The  position  of  the  patient  should 
be  a  sitting  or  standing  one  whenever  possible,  with 
the  chest  bare,  or,  from  motives  of  delicacy,  a  thin 
undershirt  may  be  permitted,  but  it  must  be  soft 
and  smoothed  out  evenly.  Again,  should  there  be 
any  danger  of  chill,  a  part  of  the  chest  may  be  ex- 
posed at  one  time,  provided  the  corresponding  re- 
gion on  the  opposite  side  is  exposed  at  the  same 
time,  so  as  to  facilitate  comparative  percussion,  or, 
while  the  anterior  surface  is  being  percussed,  for 
example,  a  small  blanket,  sack,  or  shawl  may  pro- 
tect the  back  and  shoulders.  Patients  who  are  too 
sick  or  weak  to  be  examined  in  the  sitting  posture 
should  be  placed  perfectly  level,  or  semirecum- 

bent,  the  body  and  limbs  straight  and  the  shoul-  FIG.  19.— WINTRICH'S 
,  .,  TJ.    •  •  £  \.          PERCUSSION    HAM- 

ders   quite  even.     It  is  •  an  important  fact  to  be      MER     (Tyson ) 

noted  that   the  sounds  are  apt  to  be  dulled   in 

percussing  patients  who  are  in  sunken  contact  with  heavy  bedding 

and  pillows. 

Whether  standing,  sitting,  or  lying,  the  patient  should  have  a 
comfortable,  easy,  relaxed  position.     If  sitting,  and  even  standing 


PEKCUSSIOX  77 

sometimes,  it  is  necessary  to  use  a  back  support,  otherwise  the  firm 
pressure  of  the  examiner's  pleximeter  finger  may  cause  confusion  of 
results  by  the  patient's  swaying  the  body  or  unsymmetrically  holding 
tense  the  chest  muscles  for  bracing. 

In  percussing  the  front  of  the  chest,  the  patient  standing  or  sit- 
ting, it  is  often  particularly  necessary  to  obtain  muscular  relaxation 
because  of  the  habit  some  persons  have  under  examination  of  rigidly 
swelling  their  chests  out  as  if  ashamed  to  present  less  fulness.  The 
body  and  head  must  be  erect,  without  turn  or  twist  of  either,  the 
face  as  well  as  the  chest  pointing  forward ;  the  shoulders  not  the  least 
shrugged  or  held  back,  but  allowed  to  fall  easily  and  symmetrically 
forward,  while  the  arms  hang  loosely  at  the  sides. 

To  percuss  the  lateral  and  axillary  regions  it  is  necessary  to  have 
the  arms  drawn  back,  or  still  better,  raised  by  the  hands  clasped  over 
the  head. 

In  percussing  the  back,  the  patient  should  stoop  forward  with 
arms  folded  and  a  slight  shrug  of  the  shoulders,  thus  exposing  more 
of  the  chest  by  the  outward  lift  of  the  scapulae. 

The  effects  of  the  variation  of  attitude  upon  the  movable  borders 
of  the  lungs,  and  their  relations  to  such  movable  adjacent  organs  as 
the  heart  and  liver,  will  be  mentioned  later  (see  topographical  per- 
cussion). 

The  pleximeter  finger  is  usually  the  middle  one  of  either  hand, 
according  as  one  is  right-  or  left-handed.  It  should  be  placed  hori- 
zontally between  the  ribs,  firmly  and  flatly,  and  with  the  same  degree 
of  pressure  and  on  the  same  parallel  at  the  same  relative  position 
to  any  given  vertical  line  on  the  two  sides  before  a  higher  or  lower 
interspace  is  percussed,  and  thus  always  comparing  similar  parts  on 
the  two  sides.  By  percussing  in  this  manner  only  can  the  purest  and 
most  distinctive  lung  sounds  be  elicited,  so  far  as  the  pleximeter  finger 
is  concerned.  On  thin  chests  it  is  practically  impossible  to  apply 
this  finger  evenly  except  parallel  to  the  ribs,  whether  between  them 
or  on  them.  The  true  note  is  modified  by  the  cushion  of  air  under 
a  finger  placed  slantwise  or  vertically;  also  when  the  bones  are  per- 
cussed; but  if  the  comparative  method  is  strictly  adhered  to  there  is 
less  likelihood  of  inaccuracy.  Not  infrequently,  however,  it  is  con- 
venient or  advantageous  to  apply  the  finger  at  various  angles  to  the 
ribs,  as  in  outlining  organs;  in  such  cases  the  tip  of  the  finger  may 
be  laid  in  the  interspace  so  as  to  avoid  pressure  against  a  rib;  in 
stout  individuals,  where  the  chest  wall  is  thick  and  smooth  with  flesh, 
this  is  not  so  necessary. 


78  PHYSICAL    DIAGNOSIS 

In  some  parts,  as  the  supraclavicular  and  axillary,  to  avoid  a  con- 
strained difficulty  of  percussion,  the  side  of  the  pleximeter  finger  may 
be  laid  on  the  tissues,  and  the  stroke  received  upon  the  lateral  bony 
prominence  of  the  terminal  phalangeal  joint. 

Valuable  information  may  more  readily  be  obtained  sometimes 
by  using  the  four  fingers  of  the  pleximeter  hand  laid  in  as  many  in- 
terspaces, each  finger  being  percussed  successively  with  a  single  stroke. 
Slight  differences  in  sound  near  the  borders  of  the  lungs  and  adjacent 
are  thus  especially  well  brought. 

The  plexor  finger  is  usually  the  second  or  middle  one  of  the  right 
hand  (for  right-handed  examiners).  Beginners  and  those  who  have 
never  acquired  that  facile  resiliency  of  percussion  stroke  so  essential 
for  skill  and  satisfactory  results,  are  prone  to  use  two  or  three  fin- 
gers to  percuss  with,  endeavoring  to  make  heaviness  of  blow  bring  out 
the  sound;  whereas,  if  from  the  first  close  and  patient  attention  to 
the  details  of  a  proper  technic  be  given,  and  the  diligent  practise  of 
them  be  persevered  in,  a  clearer  note  from  a  lighter,  single-fingered 
stroke  may  be  elicited,  and  the  patient's  discomfort,  and  resentment 
perhaps,  avoided.  Habitually  does  one  see  the  sophomore  "  mod," 
when  commencing  to  learn  percussion,  imitate,  as  he  thinks,  his 
teacher's  method  after  a  superficial  observation,  and,  without  a  con- 
centrated study  of  the  conditions  and  factors  of  successful  percussion, 
proceed  vigorously  to  practise  in  a  faulty  and  discouraging  manner 
that  daily  becomes  more  and  more  difficult  to  correct  and  eradicate. 

What  are  those  points  to  be  shunned  that  are  at  the  same  time 
so  easily  drifted  into?  In  the  first  place,  a  constrained,  awkward, 
and  unsymmetrical  position  on  the  part  of  the  examiner  with  regard 
to  the  patient.  The  former  should  so  place  himself  that  perfect  free- 
dom, fulness,  and  comfort  of  action  may  be  obtained,  and  maintain 
as  nearly  as  possible  equal  distances  between  the  listening  ear  and  the 
respective  parts  percussed. 

(a)  The  plexor  finger  may  not  be  flexed  enough ;  it  should  be  bent 
sufficiently  at  the  second  or  middle  joint  so  that  the  tip  of  the 
finger  falls  perpendicularly  upon  the  pleximeter  finger,  the  distal 
joint  being  fixed  as  rigidly  as  possible;  any  variation  from  this  prac- 
tise only  weakens  and  alters  the  true  character  of  the  sound,  a  slant- 
ing blow  being  a  flabby  one. 

(&)  Too  often  the  stroke  is  heavily  delivered  from  the  elbow,  or 
shoulder  even,  which,  with  the  preceding  fault,  causes  the  patient  to 
be  disagreeably  pushed  instead  of  percussed;  the  movement  should 
spring  from  the  wrist  and  be  simultaneously  reenforced  by  movement 


PERCUSSION  79 

at  the  knuckle.  It  is  only  by  accomplished  wrist  action  that  uni- 
formity and  flexibility  of  technic  are  acquired,  and  reliability  and 
nicety  of  results  obtained. 

(c)  A  lingering,  poking,   slow   stroke — that   is,   slow  in   lifting 
from  the  pleximeter  finger  after  the  delivery — is  an  essential  fault; 
the  blow  must  be  quick — that  is,  short  in  duration  of  contact;  there- 
fore it  must  have  the  rebounding,  elastic  quality,  as  of  a  piano  ham- 
mer without  the  dampening  effect  of  the  soft  pedal ;  or  the  tap  should 
be  given  with  such  immediate  removal  of  pressure  after  contact,  as 
if  one  were  percussing  resilient  rubber — smartly. 

(d)  Bearing  in  mind  that  we  must  compare  similar  parts  on  the 
right  and  left  sides  of  the  chest,  prolonged  percussion  over  one  spot 
may  j>r<>ltin</  tin-  impression  to  the  ear  so  as  to  interfere  with  its  sensi- 
lirt'nr**   to  adjacent  differences:  the  location  of  the  fingers  should 
be  changed  after  two  to  four  successive  strokes;  indeed,  it  is  better 
to  make  frequent  brief  comparisons  back  and  forth  than  to  be  satis- 
fied with  one  or  two  prolonged  hammerings. 

(e)  The  percussion  blows  should  be  delivered  with  moderate  ra- 
pidity— about  two  per  second.     When  the  blows  are  made  too  rapidly 
interference  waves  hinder  the  production  of  clear,  distinct  sounds. 

A  few  further  considerations  require  careful  notice. 

The  force  of  the  strokes  ordinarily  should  be  moderate,  always 
uniform  on  the  regions  compared,  never  painful  to  the  patient.  Ex- 
aggerated force  must  be  particularly  guarded  against  when  two  or 
three  plexor  fingers  are  used  at  once,  and  then  care  should  be  exer- 
cised to  strike  with  them  evenly.  For  simple  clinical  purposes  the 
light,  practised  stroke  given  with  one  finger  is  forcible  enough;  for 
pin-poses  of  demonstration  to  a  small  group  of  listeners,  even,  I  have 
found  it  sufficient. 

Whether  forcible  or  gentle  percussion  is  to  be  employed  depends 
upon  the  special  conditions,  and  the  object  in  view  in  each  particular 
case.  In  a  general  way  the  following  considerations  may  serve  as 
guiding  rules,  reserving  other  more  specific  ones  for  the  subject  of 
topographical  percussion  of  the  lungs.  The  stroke  should  be  rather 
forcible  in  examining  those  regions  of  the  chest  that  are  thickly 
overlaid  with  flesh — the  decidedly  muscular  and  the  decidedly  fat 
individuals.  The  clear,  resonant  pulmonary  sound  cannot  be  well 
elicited,  for  instance,  in  the  mammary  and  scapular  regions  for  ob- 
vious reasons,  unless  forcible  percussion  is  used  to  make  the  vibra- 
tions penetrate  the  thick  wall  of  the  chest.  On  the  other  hand,  lighter 
strokes  suffice  in  the  infraclavicular  and  axillary  spaces.  The  per- 


80 


PHYSICAL    DIAGNOSIS 


LUNG 


cussion  blow  must  also  be  much  less  forcible  in  children,  in  whom 
the  thoracic  walls  are  relatively  thin  and  elastic,  than  in  adults,  ex- 
cept those  who  are  very  ema- 
ciated. Indeed,  energetic 
strokes  in  such  cases  set  into 
vibration  such  a  large  volume 
of  surrounding  tissues  that  the 
quality  and  underlying  physi- 
cal causation  of  the 
sounds  to  be  denned 
over  a  small,  cir- 
cumscribed area  are 
hidden  or  confused. 
Nothing  short  of 
ease  and  elasticity 
of  wrist  percussion 
will  enable  one  so  to 
vary  the  force  of  the 
stroke  that  under 
all  circumstances 
satisfactory  results 
may  be  obtained. 
For  this  purpose  I 
have  always  recommended  to 
students  constant  practise  at 
their  study  tables  by  laying 
the  whole  forearm  flat  and  al- 
most limp  upon  the  uncovered 
wood,  and  thus  perseveringly 
getting  the  automatic  wrist 
and  finger  habit.  Variations 
of  the  blow  may  be  made  both 
in  force  and  location,  as  over 
a  table  leg,  to  note  the  differ- 
ent sound  effects;  also  with  a 
thin  table  cover  applied,  and, 
raising  the  arm,  striking  a 
book  or  a  pleximeter. 

A  contraindication  to  per- 
cussion   should    be    mentioned 


INTESTI 


1.  STRONG  =  pulmonary 
resonance  impaired 
by  liver  dulness 


GENTLE  =  pulmonary 
resonance 


3.  GENTLE  =  liver  dulness 


4.  STRONG  =  tympanitic 

resonance 


5.  GENTLE  =  liver  dulness 

6.  GENTLE  =  tympanitic 

resonance 


FIG.  20. — DIAGRAM  SHOWING  THE  RATIONALE 
AND  UTILITY  OF  VARYING  THE  FORCE  OF 
THE  PERCUSSION  STROKE.  A  strong  stroke 
as  at  1  develops  deep  dulness  and  locates 
the  upper  border  of  the  liver,  while  a  gentle 
stroke  in  the  same  spot  gives  only  pulmo- 
nary resonance.  A  gentle  stroke  at  2  gives 
pulmonary  resonance,  and  the  next  gentle 
stroke,  3,  gives  liver  dulness,  thus  locating 
the  lower  edge  of  the  lung,  while  a  powerful 
stroke  at  2  will  give  mainly  liver  dulness. 
Gentle  stroke  5  is  slightly  dull,  and  gentle 
stroke  6  is  unmistakably  tympanitic,  thus 
marking  the  boundary-line  between  thin 
edge  of  liver  and  air — containing  intes- 
tine, while  strong  stroke  4  elicits  tympa- 
nitic resonance.  (Butler.) 


here,  namely,  in  those  cases  of 


PEKCUSSION  81 

pulmonary  tuberculosis  who  shortly  before  examination  have  suffered 
from  a  hemorrhage,  or  who  may  at  the  time  be  bleeding  from  the 
lungs.  Especial  care  required  in  certain  cases  of  pneumonitis,  cav- 
ities, etc.,  will  be  referred  to  further  in  connection  with  those  sub- 
jects. 

(2)  FINGER-PLEXIMETER  PERCUSSION. — When,  as  intimated  be- 
fore, it  becomes   awkward,   difficult,   and  unsatisfactory  to  apply  a 
finger  as  pleximeter;  or  when,  as  sometimes  happens,  the  interposed 
finger  becomes  painful,  swollen,  and  even  ecchymotic,  as  I  have  seen 
occur  in  dispensary  and  ward  hospital  work,  where  numbers  of  chests 
have  to  be  percussed,   the   use  of  an  artificial  pleximeter   becomes 
a  necessity.     The  part  of  the  finger  usually  struck  is  just  back  of 
the  nail,  where  normally  there  is  a  rich  capillary  circulation;  and 
therefore  prolonged   percussion   here   may  easily   set   up   a  painful 
hyperemia  during  a  series  of  examinations,   although   this   can   be 
prevented  by  striking  the  middle  phalangeal  bone  instead  of  the  distal 
one,  habitually  or  temporarily.     However,  it  is  in  such  cases  that  a 
Sansom's  pleximeter,  for  example,  may  be  substituted. 

In  applying  the  pleximeter,  the  same  care  regarding  firmness 
and  evenness  should  be  observed  as  with  the  finger.  It  should  not 
be  forgotten  that  because  of  its  hardness  an  ivory  or  celluloid  or 
gutta-percha  pleximeter  may  be  pressed  so  firmly  as  to  hurt ;  and  that 
because  of  its  coldness,  according  to  the  weather,  it  may  produce 
disagreeable  chilliness  of  the  surface,  and  must  be  hand-warmed 
before  using. 

Again,  judicious  allowance  must  be  made  for  the  sound  produced 
in  striking  the  pleximeter  itself,  and  not  let  its  clack  overshadow  the 
chest  sounds  from  within.  This  may  be  guarded  against,  in  one  way 
at  least,  by  preserving  shortness  of  the  nails,  and  by  insuring  the 
contact  of  the  plexor  finger  at  its  rounded  end,  about  midway  between 
the  nail  and  the  palmar  pulp. 

(3)  HAMMER-PLEXIMETER    PERCUSSION. — This    method    is    the 
easiest  to  master,  but  is  generally  too  ostentatious,  and  may  be  terri- 
fying to  timid  patients.    Nevertheless,  it  has  a  few  occasional  advan- 
tages.   Thus,  until  finger  percussion  has  been  learned  with  skill  suf- 
ficient to  elicit  the  true  sounds  of  a  given  region  the  student  may 
practise  the  recognition  and  discrimination  of  those  sounds  brought 
out  more  distinctly  with  the  percussion  hammer  and  pleximeter — 
train  the  ear  while  the  fingers  are  catching  up.     The  hammer  taps 
should  be   delivered  with   equal,  gentle  force,  equal  frequency  and 
rapidity  on  the  two  sides  and  similar  areas  of  the  chest. 

8 


82  PHYSICAL   DIAGNOSIS 

When  for  any  reason,  as  for  the  detection  of  deeply  seated  growths, 
consolidations,  and  cavities,  it  is  desired  to  make  the  vibrations  pene- 
trate deeper  into  the  thorax,  hammer-pleximeter  percussion  is  a  useful 
adjunct.  In  other  cases,  the  erroneous  results  one  is  apt  to  be  led  into 
by  the  too  penetrative  power  of  this  method  setting  into  vibration 
too  large  volumes  of  resounding  substance,  and  the  disadvantage 
of  the  sense  of  resistance  experienced  in  finger  percussion,  may  be 
avoided  by  percussing  with  a  very  light  stroke,  and  by  grasping  ihe 
hammer  not  at  the  end,  but  at  the  middle  of  the  handle,  and  at  the 
same  time  keeping  the  index  finger  closely  applied  to  the  hammer 
head. 

We  may  summarize  by  stating  that  finger  percussion  is  the  most 
valuable  and  generally  useful  method,  really  must  be  acquired  SODIUM- 
or  later,  and  although  the  most  difficult  to  gain  technical  skill  in, 
when  once  achieved  yields  the  best  results,  and  makes  easy  the  prac- 
tise of  other  methods,  which  is  not  true  conversely.  Again,  the  im- 
portance of  always  comparing  corresponding  portions  on  the  two 
sides  under  the  same  conditions  of  posture  and  technic  must  not  be 
forgotten. 

Respiratory  Percussion. — Ordinary  quiet  respiration  does  not 
affect  the  constancy  of  the  percussion  sound,  which  is  of  average  qual- 
ity in  this  respect.  But  to  make  assurance  doubly  sure,  the  two  sides 
of  the  chest  should  be  percussed  comparatively  during  the  same  stages 
of  the  breathing  act;  that  is,  a  note  elicited  during  inspiration  on  the 
right  side  should  be  compared  with  one  during  inspiration,  and  not 
expiration,  on  the  left  side,  and  vice  versa,  especially  if  the  breathing 
is  a  little  exaggerated. 

The  term  respiratory  percussion  is  more  specifically  applied,  how- 
ever, to  the  perception  of  differences  of  sound  at  the  end  of  a  deep 
inspiration  or  of  a  full  expiration,  the  patient  holding  the  breath  in 
each  instance.  The  conditions  affecting  this  test  in  general  will  be 
noted  in  discussing  the  attributes  of  sounds  obtained  in  percussing 
over  the  lungs. 

Auscultatory  or  Stethoscopic  Percussion. — This  useful  method, 
which  deserves  much  more  practical  attention  and  application  than 
it  has  received,  was  introduced  by  Drs.  Cammann  and  Clark,  of  New 
York,  in  1840. 

The  method  combines  listening  with  the  stethoscope  with  per- 
cussion. The  original  stethoscope  of  Cammann  was  a  solid  piece 
of  wood  about  six  inches  in  length  and  three-fourths  of  an  inch  in 


PERCUSSION 


83 


LINE  Or  BEST 
CONDUCTION. 


SOUND  DISTANT 
AND  INDISTINCT. 


SOUND  DIRECT 
CLEAR  AND  LOUDER. 


STETHOSCOPE. 


diameter,  with  an  ear  piece  firmly  attached  to  it.  The  binaural 
stethoscope  is  now  used.  The  technic  consists  in  placing  the  chest 
piece  of  the  latter  (the  bell  of 
which  should  be  small  enough 
to  rest  snugly  between  the  ribs) 
over  the  organ  whose  outlines 
are  to  be  studied,  and  percuss- 
ing lightly  toward  it  from  dif- 
ferent points  beyond  the  sup- 
posed borders  of  the  organ, 
tumor,  or  other  pathologic  for- 
mation. At  times  it 
may  be  more  satisfac- 
tory to  have  an  assist- 
ant hold  the  chest  end  of  the 
stethoscope;  or,  as  some  pre- 
fer, so  as  to  avoid  the  modify- 
ing vibrations  of  the  bony 
thorax,  the  percussion  notes 
may  be  listened  to  with  the 
bell  of  the  stethoscope  sus- 
pended a  little  above  and  near 
the  point  of  percussion.  Again, 
as  with  the  use  of  the  phonendoscope  (see  instruments  for  ausculta- 
tion) for  the  same  purpose,  instead  of  pleximetric  percussion  a  strok- 
ing or  scratching  with  the 
index  finger  may  be  done 
upon  the  skin  near  the 
chest  piece,  the  changes  of 
sound  conducted  being 
thus  noted. 

By  this  method  the 
sounds  produced  are 
louder  and  more  distinct 
than  when  communicated 
simply  through  the  air 
without  the  aid  of  a  steth- 
FIG.  22.— DIAGRAM  SHOWING  THE  LINES  TO  WHICH  oscope.  Besides,  changes 

AUSCULTATORY   PERCUSSION   SHOULD    BE   CAR-  in      qUdllty      and      pitch      &TQ 

RIED  IN  ORDER  TO  OUTLINE  AN  ORGAN     The        noted      moJ.Q      readi]          fn 
central  circle  represents  the  chest  piece  of  the 

stethoscope.    (Butler.)  passing  the  boundaries  of 


FIG.  21. — DIAGRAM  SHOWING  THE  THEORY 
OF  AUSCULTATORY  PERCUSSION.  The  or- 
gan over  which  the  stethoscope  is  placed 
may  be  either  solid  or  hollow.  (Butler.) 


84  PHYSICAL    DIAGNOSIS 

organs,  and  hence  the  latter  may  be  marked  more  precisely.  The 
character  and  intensity  of  the  percussion  note  continue  the  same  so 
long  as  the  stethoscope  and  finger  are  over  the  same  organ  or  patho- 
logic formation;  but  become  altered  and  weakened  at  once  when  the 
limits  are  reached  by  either.  The  value  of  the  application  of  this 
delicate  technic  in  the  outlining  of  such  organs  and  morbid  condi- 
tions as  the  heart,  stomach,  liver,  and  spleen,  and  thoracic  aneurism 
is  quite  evident,  and  as  employed  there  will  be  described  under  their 
topographic  examination.  However,  in"  delimiting  the  lung  borders, 
and  even  the  lobes  of  the  lungs,  in  discriminating  a  pulmonary  con- 
solidation from  a  pleural  effusion,  and  both  from  normal  or  enlarged 
liver,  auscultatory  percussion  may  be  of  marked  service.  (See  Figs. 
21  and  22.)  As  Cabot  points  out,  to  insure  reliable  results  from  this 
method  the  percussion  must  be  made  along  arcs  of  circles  in  approach- 
ing the  presumed  borders  of  an  organ,  thus  keeping  the  chest  piece 
at  all  times  and  in  changing  locations  at  an  equidistant  center,  other- 
wise the  intensity  and  quality  of  the  sounds  transmitted  will  vary  with 
the  longer  or  shorter  lines  of  distance  and  so  give  the  false  impres- 
sion of  different  organic  tissues. 

Palpatory  Percussion. — Not  only  do  we  study  the  sounds  elicited 
by  percussion,  but  the  sensation  of  resistance  to  both  fingers,  espe- 
cially the  plexor  finger,  is  also  appreciated.  It  partakes  of  palpation 
as  well  as  of  percussion.  It  is  influenced  by  the  degree  of  capacity  of 
the  underlying  parts  to  vibrate;  the  sense  of  resistance  is  slight  over 
air-containing,  resilient  tissue,  while  the  denser  the  structure  the 
greater  the  resistance. 

It  is  the  estimation  of  this  amount  of  resistance  which  enters  most 
essentially  into  the  performance  of  palpatory  percussion,  which  re- 
sorts to  a  sort  of  pushing  stroke.  Two  or  three  fingers  of  the  plexor 
hand  are  partly  flexed  so  that  the  pulps  strike  or  push  against  the 
pleximeter  finger  from  a  shorter  distance  above  the  latter  than  in 
ordinary  percussion,  and  the  rebounding  stroke  is  also  replaced  by 
longer  contact — "palpating  stroke."  To  some  clinicians  palpatory 
percussion  is  often  more  delicate  than  auditory  percussion  for  the 
purpose  of  mapping  out  organs.  The  light,  inaudible  tapping  elicits 
vibratory  sensations,  the  perception  of  which  is  attributed  by  the  Eus- 
sian,  Tranoff,  to  a  sort  of  dermal  hearing — the  ability  of  the  skin 
to  differentiate  the  quality,  force,  and  pitch  of  peripheral  vibrations. 
When  forcible  auditory  percussion  is  contraindicated,  as  in  hemop- 
tysis, or  when  it  is  useless,  as  in  crying  children,  or  when  the  physi- 
cian's sense  of  hearing  is  defective,  this  method  may  be  invaluable, 


PERCUSSION  85 

though  every  physician  should  endeavor  to  cultivate  his  "  skin-sense 
of  vibrations."  The  method  is  not  as  commonly  used  in  this  country 
as  in  Germany. 

Superficial  and  Deep  Percussion. — These  terms  are  used  frequently 
to  describe  respectively  the  lighter  blows  given  to  elicit  sounds  only 
from  tissues  directly  under  the  chest  wall,  as  the  thinner  layers  of 
lung  partly  covering  the  heart  and  liver,  and  the  heavier  blows  given 
to  bring  out  the  sounds  of  pathologic  formations  deeply  situated  in 
the  lungs,  or  of  solid  organs  overlapped  considerably  by  the  lungs. 


THORACIC    PERCUSSION    SOUNDS 

The  foundation  fact  upon  which  the  practise  of  percussion  of  the 
body  depends  is,  that  some  of  the  principal  organs  contain  air  or  gas, 
or  both,  and  that  there  are  more  or  less  characteristic  differences  in 
the  sounds  produced  by  percussing  over  them  on  account  of  certain 
normal  (mainly  anatomic)  conditions,  and  pathologic  changes  affect- 
ing them  or  contiguous  organs  or  tissues. 

To  understand  and  interpret  these  variations  of  sound  one  must 
]>e  acquainted  with  the  physical  properties  that  characterize  them, 
for  it  is  upon  a  clear  perception  and  analysis  of  these  that  their 
diagnostic  significance  rests.  After  a  time  they  become  distinguish- 
able witli  a  speed  that  seems  intuitive,  but  is  simply  the  outcome  of 
an  established  and  assured  habit  of  painstaking  and  precise  recog- 
nition. 

Percussion  over  air- containing  structures  gives  rise  to  a  more  or 
less  dear  tone,  of  a  resounding  character  over  normal  lung,  drumlike 
over  the  stomach  and  bowels. 

But  when  we  percuss  over  solid,  airless  tissues  or  organs,  the 
sound  elicited  is  absolutely  dull  or  deadened,  like  that  obtained  by 
striking  upon  the  thigh,  hence  also  "  thigh  sound/'  It  lacks  the 
uniformity  and  regularity  of  vibrations  of  the  clear,  almost  musical 
tones  from  percussed  organs  containing  air,  as  the  pulmonary  vesicles ; 
it  is  a  noise,  dead  and  flat. 

As  there  are  many  gradations  between  the  tonelessness  elicited 
over  solid  organs  and  the  clearness  of  normal  pulmonary  resonance, 
and  as  both  extremes,  and  the  intervening  grades  of  "  impaired  reso- 
nance "  or  "  relative  dulness,"  are  really  recognized  by  their  physical 
attributes,  an  analytic  study  of  these  is  necessary  before  their  special, 
practical  application  is  made  in  the  percussion  of  the  normal  and 


86  PHYSICAL   DIAGNOSIS 

pathologic  lungs.  However,  the  relation  of  these  acoustic  elements  to 
illustrative  healthy  and  morbid  conditions  of  the  lungs  will  be  desig- 
nated in  a  general  way,  in  preparation  for  the  easier  apprehension 
of  their  significance  in  the  diagnosis  of  the  special  pulmonary  diseases. 

ATTRIBUTES  OF  PERCUSSION   SOUNDS 

In  judging  percussion  sounds,  we  note  four  attributes:  (A)  Qual- 
ity, (B)  intensity  or  volume;  (C)  pitch;  (D)  duration.  None  of 
these  can  actually  or  adequately  be  learned  from  descriptions  alone; 
they  must  be  recognized  by  ear  practise,  to  which  the  definitions  and 
illustrations  here  given  may  render  intelligent  direction  and  per- 
ception. 

(A)  Quality,  in  physics,  is  that  peculiar,  essential  property  which 
distinguishes  sounds  from  different  sources,  although  the  other  prop- 
erties may  be  alike.  It  corresponds  to  the  timbre  of  a  musical  tone,  by 
which  we  appreciate  its  instrumental  source,  whether  of  the  stringed, 
brass,  or  reed  class,  whether  a  single  instrument  of  each  class,  as  a  violin, 
trombone,  or  clarinet,  regardless  of  similarities  or  alterations  of  pitch 
and  intensity.  Quality  is  that  distinct  characteristic  of  a  sound  which 
makes  it  what  it  is,  and  which  it  cannot  lose  "  without  ceasing  to  be." 

Given  the  associated  structural  conditions  of  a  pipe-organ  or  harp, 
for  example,  the  tones  of  which  one  has  heard  often  enough  to  be 
familiar  with,  and  as  either  instrument  may  then  be  readily  recog- 
nized by  its  tonal  quality,  though  not  visible  to  the  listener,  so  one 
must  strive  to  gain  familiarity  with  normal  and  abnormal  physical 
conditions  and  changes  of  the  lungs  by  and  through  the  quick  per- 
ception of,  and  swift,  deduction  from,  the  attribute  of  quality. 

As  indicated  before,  there  are  two  extremes  of  quality  heard  in 
percussing  over  the  lungs  (or  body):  (1)  the  dear  sound  of  air- 
containing  tissue;  (2)  the  dead  or  absolutely  dull  sound  of  airless 
tissue.  The  term  clearness  is,  of  course,  a  relative  one,  its  degree 
depending  upon  the  volume  of  air-containing  tissue,  other  things 
being  equal. 

We  meet  with  two  distinct  qualities  of  clear  sound:  (1)  nontym- 
panitic  or  resonant  sound;  (2)  tympanitic  sound. 

(1)  RESONANT  SOUND. — The  former  of  these,  more  commonly 
designated  as  the  normal  pulmonary  resonance,  or  normal  vesicular 
resonance.,  is  the  characteristic  clear  lung  sound  elicited  by  percussing 
over  healthy  vesicular  air  structure  physiologically  distended.  Al- 
though its  quality  has  been  likened  to  the  sound  obtained  by  gently 


PERCUSSION  87 

striking  a  drum  covered  with  a  thick  woolen  cloth  (Auenbrugger), 
or  to  that  produced  by  percussing  over  the  upper  crust  of  a  loaf  of 
bread  covered  with  a  towel  (Flint),  nevertheless  its  sui  generis  quality 
must  be  heard  and  learned  by  experience  from  each  individual  exam- 
ined rather  than  from  any  description,  however  discriminating.  Pul- 
monary resonance  is  distinctive  enough  to  permit  variations  from  the 
normal  to  be  easily  recognized. 

The  quality  of  the  normal  pulmonary  resonance  is  probably  influ- 
enced by  the  peculiar  sound  contributed  by  the  bony  formation  of  the 
chest  wall,  as  when  the  slightly  inflated  lung  that  has  been  removed 
from  the  dead  body  is  percussed,  the  sound  is  drumlike  or  tympanitic. 

The  clearness,  though  not  the  distinctiveness  of  note,  is  modified 
a  little  also  according  to  the  locality  percussed,  owing  to  the  effect 
of  intervening  thoracic  bone,  muscle,  and  fat.  This  will  be  pointed 
out  more  appropriately  under  topographic  percussion.  The  typical 
quality  of  normal  vesicular  resonance  is  usually  best  heard  in  per- 
cussing over  the  left  infraclavicular  region,  or  below  the  scapular 
angles  in  chests  that  are  not  fat  or  too  muscular.  Sometimes  I  have 
found  it  helpful  in  demonstrating  the  pulmonary  resonance  to  per- 
cuss over  the  empty  stomach,  and  thus  compare  the  clear,  tympanitic 
quality  of  the  latter  with  the  characteristic  reverberating  variety  of 
the  former;  the  differences  of  sound  are  pronounced,  so  that  their 
pathologic  association  may  more  readily  be  detected,  as  in  the  occur- 
rence of  cavity  of  the  lung  (tympanitic  quality  with  high  pitch). 

The  cause  of  the  normal  vesicular  resonance  is  probably  the  com- 
bined vibration  of  the  chest  wall,  alveoli  of  the  lungs,  the  bronchi, 
and  their  contained  air.  Therefore,  the  clearness  or  fulness  of  reso- 
nance will  depend  upon  the  conditions  of  these  elements. 

The  modifying  conditions  which  give  rise  to  variations  in  the  tone 
of  resonance  in  health  are  the  following  four: 

(a)  Thickness   of   the   Chest   Wall. — The   greater  the  thickness 
the  duller  the  resonance,  and  vice  versa.     Muscularity,  unless  very 
marked,  does  not  influence  clearness  very  much.     On  the  other  hand, 
the  thick  layers  of  nonelastic  adipose  tissue  in  stout  individuals  dulls 
the  resonant  quality  considerably.     Per  contra,  percussion  over  the 
emaciated  chest  of  a  patient  with  healthy  lungs,  but  dying  with  cancer 
in  the  abdomen,  elicits  very  clear  resonance  with  ready  facility. 

(b)  Influence  and  Resilience  of  the  Osseous  and  Cartilaginous 
Framework. — Since,  as  mentioned  previously,  the  healthy  lung  re- 
moved from  the  body  yields  a  tympanitic  or  drumlike  sound  when 
percussed,  it  is  owing  to  the  material  influence  of  the  thoracic  wall 


88  PHYSICAL    l)IA(i.\()SIS 

in  the  living  subject  that  percussion  over  its  surface  correspond- 
ing to  the  pulmonary  regions  elicits  the  special  quality  of  the  vesic- 
ular resonance,  or  "  muffled  "  tympanitic  sound,  as  it  has  been  called. 
It  should  be  borne  in  mind  that  bone,  when  thinly  covered  and  per- 
cussed, has  a  peculiar  resonance  of  its  own.  This  is  particularly 
marked  as  regards  the  sternum,  and,  to  a  slightly  less  degree,  the 
clavicles  and  ribs.  The  close  and  cagelike  framework  of  the  bones 
of  the  thorax  permits  the  vibrations  of  a  percussion  blow  to  be  trans- 
mitted generally  over  other  portions  of  the  bony  thorax.  It  is  for 
this  reason  that  the  percussion  strokes  should  be  delivered  mostly  in 
the  intercostal  spaces  so  as  to  get  the  purest  lung  sound.  The  sternum 
acts  as  a  natural  sounding-board,  and  unless  the  anterior  mediastinum 
is  practically  filled  with  a  mass  of  firm  tissue  the  sternal  note  is  uni- 
formly and  peculiarly  resonant,  seemingly  gathering  up  and  intensi- 
fying the  totality  of  pulmonary  and  mural  vibrations  set  up. 

The  clearness  of  the  lung  resonance  likewise  depends  upon  the 
resilience  of  the  osseous  thorax,  and  this  upon  the  age  of  the  subject. 
In  children,  whose  ribs  are  very  flexible,  the  resonance  is  decidedly 
clearer  than  in  adults;  on  account  of  the  more  rigid  and  resistant 
conditions  of  the  chest  wall  in  the  latter,  especially  in  the  aged,  there 
is  more  interference  with  the  purity  of  the  lung  sound  on  percussion, 
and  an  overshadowing  prominence  of  the  "wooden"  bony  sound. 

(c)  Amount  of  Air  Within  the  Respiratory  Tract. — The  vesicu- 
lar resonance  has  a  clearer  quality  in  persons  who  are  good  breath- 
ers— whose  respiratory  expansion  and  vital  capacity  are  good.     We 
usually  find  this  in  athletes,  and  others  whose  occupation,  health- 
ful exercise,  and  physical  culture  compel  them  to  fill  their  lungs  well. 
The  resonant  lung  quality  is  lacking,  on  the  other  hand,  in  those 
who  are  deficient  in  the  volume  of  respiratory  air :  full  lungs  produce 
full  vesicular  resonance. 

(d)  Presence  of  Adjacent  Organs. — That  the  characteristic  pul- 
monary resonance  is  diminished  in  clearness  near  the  borders  of  such 
solid  organs  as  the  heart  and  liver  is  an  important  consideration  in 
estimating  their  respective  limits.     Again,  the  influence  of  the  ad- 
jacent distended  stomach  upon  the  left  lung  sound  is  to  superadd 
its  drumlike  tone,  which  thus  develops  a  tympanitic  resonance,  prin- 
cipally over  the  lower  half  of  the  chest,  anterolaterally. 

(2)  TYMPANITIC  SOUND. — The  tympanitic  sound  exists  normally 
and  typically  over  the  stomach  moderately  distended  with  air  or  gas, 
and  not  over  the  lung  except  pathologically.  With  less  fulness  of 
quality,  tympanitic  resonance  is  also  heard  in  percussing  over  the 


PEKCUSSION  89 

colon  and  larynx,  also  over  the  distended  cheeks,  this  variation  of 
quality  being  due  to  variations  of  the  attributes  of  intensity  and  pitch 
because  of  smaller  volumes  of  air. 

Tympanitic  sound  simulates  very  closely  that  of  the  tympanon  or 
kettle-drum,  and  approximates  a  musical  tone.  Its  clearness  depends 
upon  such  factors  as  influence  the  pulmonary  resonance,  especially 
the  thickness  of  the  intervening  tissue  and  the  volume  of  contained 
air ;  besides  these,  the  tension  of  the  air-  or  gas-containing  walls  is 
important. 

Two  subvarieties  of  the  tympanitic  sound  are  noted,  namely,  the 
open  and  the  closed. 

The  open  tympanitic  sound  occurs  in  percussing  over  cavities  con- 
taining air  or  gas,  if  surrounded  by  walls  "  moderately  smooth  and 
capable  of  reflexion,  and  if  they  communicate  with  the  external  air 
through  an  opening,  the  walls  being  stiff  or  yielding." 

The  closed  tympanitic  sound  is  produced  over  cavities  or  organs 
without  communicating  freely  with  the  external  air  by  openings,  the 
walls  being  thin,  membranous,  and  not  too  tense.  Pathologically, 
lung  cavities  in  direct  communication  with  bronchi  are  examples  of 
causes  of  the  open  tympanitic  sound,  while  closed,  isolated  cavities 
and  closed  pneuinothorax,  as  well  as  the  normal  state  of  the  stomach, 
exemplify  the  second.  These  qualities  are  recognized  mainly  by  dif- 
ferences in  pitch,  as  will  be  pointed  out  in  describing  that  attribute. 

(3)  THE  DULL  OR  DEAD  SOUND. — The  absolutely  dull  or  dead 
sound  has  the  toneless  quality  and  does  not  occur  over  normal  lung, 
simply  because  such  lung  always  contains  more  or  less  air;  and 
yet  this  qualification  implies  that  the  degree  of  clearness  of  quality 
does  vary  according  to  the  amount  of  air  present,  principally,  in  a 
given  portion  of  the  lungs;  hence  the  commonly  used  term  relative 
dulness  for  all  intervening  grades  between  clearness  less  than  abso- 
lutely full  and  pronounced  and  dulness  absolutely  flat  and  dead,  as 
obtained  over  solid,  airless  tissues  or  organs.  The  latter  are  exem- 
plified in  the  case  of  the  thigh  sound  obtained  in  percussing  over  the 
skeletal  body  coverings,  over  uncovered  liver,  heart,  and  spleen,  and 
over  the  following  pathological  conditions:  (a)  The  interposition  of 
liquid  or  solid  material,  as  pleuritic  effusions  or  thickening,  between 
the  lung  and  chest  wall,  (&)  or  the  infiltration  of  vesicular  tissue 
and  air-spaces  with  solid  substance,  as  in  the  marked  consolidation 
of  pneumonitis. 

While  the  terms  dulness,  flatness,  and  deadness  are  used  inter- 
changeably to  indicate  the  absence  of  air,  in  common  usage  a  dull 


90  PHYSICAL    DIAGNOSIS 

sound  is  more  particularly  elicited  where  the  resonance  is  very  posi- 
tively diminished;  a  dead  or  flat  sound  where  we  percuss  over  abso- 
lutely airless  organs,  solid  growths,  and  liquid  accumulations,  the 
latter  corresponding  to  condition  (a)  and  the  former  to  condition  (&) 
of  the  preceding  paragraph. 

Clinical  language  also  employs  such  qualifying  words  to  express 
varying  degrees  of  dulness  as  marked  or  considerable,  moderate  or 
slight,  the  two  last  terms  meaning  virtually  relative  dulness,  that  is, 
the  presence  of  a  slight  amount  of  air  directly  beneath  or  adjacent 
to  the  part  percussed,  so  that  the  sound  possesses  just  sufficient  reso- 
nance to  escape  being  a  noise — toneless. 

In  the  case  of  very  fat  persons,  owing  to  the  great  thickness  of 
the  chest  walls,  percussion  over  normal  lungs  with  exaggerated  force 
may  yield  only  a  deadened  sound,  the  vibrations  not  penetrating 
deeply  enough. 

Dulness  is  also  obtained  frequently  over  the  most  prominent  angu- 
larity of  bone  in  the  kyphoscoliotic  thorax  consistent  with  a  healthy 
state  of  the  subjacent  lung. 

Relatively  dull  sound  as  a  normal  quality  occurs  both  as  diminished 
vesicular  resonance  and  diminished  tympany.  It  results  from  per- 
cussing a  solid  organ  having  a  small-sized  or  thin  layer  of  air- 
containing  structure  between  it  and  the  chest  wall,  as  where  the 
lung  overlays  the  heart  and  liver,  or  from  percussion  over  air- 
containing  tissue  with  a  thin  layer  of  airless  tissue  intervening,  as 
where  the  lower  border  of  the  liver  comes  between  the  large  bowel 
and  the  body  wall.  The  former  of  these  conditions  gives  rise  to 
normal  vesicular  dulness,  the  latter  to  normal  tympanitic  dulness. 

(B)  Intensity. — This  is  simply  loudness,  and  depends  upon  the 
amplitude  of  the  vibrations,  producing  volume  or  mass  of  sound 
heard  at  varying  distances. 

A  clear  sound  is  always  louder  than  a  dull  or  dead  sound ;  there- 
fore, if  in  percussing  over  air-containing  tissue  of  normal  clearness 
and  loudness  we  pass  to  parts  that  gradually  or  sharply  diminish  in 
loudness,  we  know  that  underneath  lies  more  or  less  airless  structure. 

The  intensity  of  the  tympanitic  sound  is  greater  than  that  of  lung 
resonance,  volume  for  volume  and  other  things  being  equal;  for  in- 
stance, a  stomach  distended  with  air  or  gas  to  the  capacity  of  the 
left  lung  elicits  a  clearer  and  louder  tone  than  the  latter,  where  the 
structure  consists  of  numerous  little  air  vesicles  formed  by  consider- 
able spongy  tissue  instead  of  one  large,  free  viscus.  In  disease  of  the 
lung,  however,  the  intensity  of  the  tympanitic  note  over  a  tubercular 


PERCUSSIOX  91 

cavity  is  softer  than  over  the  surrounding  vesicular  substance,  for  the 
reason  that  smaller  volume  affords  less  amplitude,  and  hence  less 
acoustic  force,  than  larger  volume. 

The  loudness  of  resonant  sounds  depends  upon  three  conditions: 
(1)  The  force  of  the  percussion  stroke;  (2)  the  thickness  and  elas- 
ticity of  the  chest  wall;  (3)  the  volume  of  the  air-containing  parts 
set  in  vibration. 

( 1 )  THE  FORCE  OF  THE  BLOW  bears  a  direct  relation ;  ceteris  part- 
bus,  the  stronger  it  is  the  greater  the  intensity,  as  in  striking  a  drum- 
head ;  the  loudness  varies  while  the  quality  remains  the  same.     Modi- 
fications of  the  strength  of  the  percussion  blow  will  be  considered 
later   in   their   application   to   delimiting   organs,   the  lung  borders 
especially. 

(2)  The  greater  the  THICKNESS  OF  THE  CHEST  WALL  the  less  the 
intensity;  and,  conversely,  the  nearer  the  air-containing  organ  to  the 
finger  percussing,  the  less  the  muffling  of  sound,  provided  the  strokes 
are  delivered  with  equal  force.     Elasticity  of  the  thoracic  framework 
enhances  the  intensity. 

(3)  THE  AMOUNT  OF  AIR-CONTAINING  TISSUE  SET  IN  MOTION  in- 
fluences loudness  in  direct  ratio;  the  greater  the  amount  the  louder 
the  sound,  and  vice  versa.     That  is,  using  the  drum  as  illustration, 
with  equal  strength  of  blows  and  thickness  of  membrane,  the  sound 
of  bass  is  louder  than  that  of  small  or  kettle-drum. 

(C)  Pitch. — In  music,  pitch  is  the  elevation  or  depression,  the 
acuteness  or  gravity  of  the  scale  notes,  depending  upon  the  rate  or 
rapidity  of  the  vibrations  per  unit  (second)  of  time.  The  more 
rapid  the  vibrations  the  higher  the  pitch;  at  the  same  time  they  are 
shorter  in  wave  length  than  those  which  produce  the  lower  tones. 
Percussion  sounds  vary  so  in  pitch,  even  in  the  normal,  that  only  the 
talented  or  cultivated  ear,  or  both,  suffices  to  give  the  practised  famil- 
iarity to  detect  the  slight  differences  of  pitch  of  diagnostic  or  prog- 
nostic significance.  Changes  in  quality  are  more  readily  appreciated, 
but  as  these  are  often  recognized  by  this  very  attribute  of  pitch, 
sharpness  in  the  sensitiveness  to  fine  degrees  of  the  latter  adds  im- 
mensely to  the  early  discovery  of  incipient  pulmonary  disease. 

Pitch  is  the  most  important  element  in  the  differential  diagnosis 
of  airless  from  air-containing  tissue,  and  in  outlining  by  percus- 
sion the  borders  of  adjacent  or  overlapping  organs  of  clear  and  dull 
sounds,  as  the  lungs  from  the  heart  or  liver,  spleen  from  stomach, 
etc.  The  transition  from  clearness  to  deadness  is  realized  more  by 
the  gradual  elevation  of  pitch  than  by  any  other  acoustic  attribute, 


92  PHYSICAL   DIAGNOSIS 

for  the  less  the  amount  of  air  in  the  lung  the  duller — the  noisier — 
the  sound  and  the  higher  the  pitch. 

The  relation  of  intensity  to  pitch  is  this:  The  louder  or  clearer 
the  sound  the  lower  the  pitch;  the  higher  or  shriller  the  sound  the 
less  its  loudness.  Again  the  illustration  of  the  large  and  small  drums 
holds:  the  low-pitched  bass  drum  emits  a  louder,  farther-carrying 
sound  than  the  higher-pitched  kettle-drum. 

Similarly,  a  clear  sound  has  a  low  pitch,  and  is  consequently 
louder  than  a  dull  one,  which  has  a  comparatively  high  pitch. 

A  word  of  caution  is  needed  here  to  the  student,  namely,  not  to 
confuse  the  high-pitched,  dull  sound  with  the  high-pitched  tympan- 
itic  note  often  met  with  over  small  cavities  of  the  lung,  for  example. 

Other  factors  being  equal,  the  pitch  of  the  tympanitic  tone  is 
lower — and  at  the  same  time  louder — than  the  pulmonary  resonance. 
Practically,  however,  as  far  as  size  is  concerned,  only  the  occurrence 
of  a  dilated  stomach  affords  a  demonstration  of  this  physical  fact. 
This  leads  to  the  very  important 

CONDITIONS  THAT  INFLUENCE  THE  PRODUCTION  AND  VARIATION 
OF  PITCH. — In  general,  the  larger  the  cavity  containing  air  the  lower 
the  pitch ;  therefore,  owing  to  the  volume  of  the  lungs,  the  pitch  of  the 
normal  percussion  sound  is  distinctly  low  over  them.  As  the  vesicular 
tissue  is  elastic,  however,  the  degree  of  tension  is  also  a  factor  influ- 
encing the  pitch  both  physiologically  and  pathologically  in  respiratory 
conditions.  Ordinarily  the  lung  vesicles  are  not  in  a  state  of  high 
tension;  therefore,  if  the  tension  is  increased  and  the  vesicles  forcibly 
distended,  the  pitch  is  raised,  as  at  the  end  of  a  forced  inspiration; 
or  again,  at  the  end  of  a  deep  expiration,  the  vesicles  being  relaxed, 
the  pitch  is  relatively  lowered.  In  the  former  case  we  hear  what 
Flint  termed  vesiculotympanitic  resonance;  in  the  latter,  the  sound 
is  exaggerated  a  little  in  clearness  and  loudness,  and  becomes  hyper- 
resonance.  Whenever,  as  in  certain  diseased  conditions  that  will  be 
referred  to  later,  the  degree  of  relaxation  becomes  so  marked  that  the 
vesicles  are  in  a  state  of  elastic  equilibrium — the  inspiratory  and 
expiratory  pressure  being  about  equal — tympanitic  quality  is  elicited 
with  still  lower-pitched  and  louder  sound,  as  when  healthy  lung,  re- 
moved from  the  body,  is  percussed. 

It  has  been  affirmed  by  some  clinicians  that,  contrary  to  what  has 
just  been  said,  the  pitch  is  lowered  with  the  increased  tension  of  the 
vesicular  tissue  at  the  height  of  inspiration.  This  apparent  contra- 
diction is  due  to  not  taking  into  account  the  conditions  of  expansion 
and  the  volume  of  lung  in  certain  individuals  in  relation  to  the  ten- 


PEKCUSSION  93 

sion.  To  begin  with,  as  an  independent  factor,  and  other  things 
being  alike,  the  presumption  is  in  favor  of  the  explanation  first  given, 
since  it  is  in  harmony  with  a  law  of  physics  that  the  greater  the 
tension  of  a  membrane  the  higher  the  pitch.  Also,  it  is  true  that 
the  larger  the  volume  the  lower  the  pitch  is.  Hence,  the  whole  matter 
resolves  itself  into  a  question  of  the  relative  predominance  of  one  or 
other  condition  with  either  portion  of  the  respiratory  act.  That  is, 
if  in  one  case  the  expansive  capacity  of  the  lungs  is  so  marked  that 
with  a  full  inspiration  the  volume  of  air-containing  tissue  increases 
relatively  more  than  the  tension  of  its  walls,  then  the  pitch  will  be 
lower  than  with  ordinary  quiet  breathing.  On  the  other  hand,  in  a 
chest  with  feebler  power  of  respiratory  expansion,  the  tension  may  be 
increased  out  of  all  proportion  to  the  increase  of  volume,  which  would 
result  in  an  inspiratory  elevation  of  pitch.  This  exposition  is  given 
here  not  so  much  because  of  any  practical  importance,  but  because 
the  student  may  more  thoroughly  and  clearly  grasp  the  principles 
involved,  for  wider  application  later,  by  thinking  out  such  a  funda- 
mental problem  in  physical  diagnosis  as  this  is. 

The  influence  of  the  chest  watt  on  pitch  is  practically  confined  to 
its  thickness  or  density,  or  to  its  tension.  Increase  of  these  elements 
produces  higher  pitch.  Indeed,  it  is  probable  that  the  tension  of  the 
chest  wall  is  more  important  in  determining  the  degree  of  pitch  than 
that  of  the  lung  substance. 

The  pitch  of  the  normal  lung  resonance,  then,  as  compared  with 
the  conditions  ordinarily  met  with,  is  low;  at  the  end  of  a  forced 
expiration  it  is  a  trifle  lower;  with  a  still  greater  (abnormal)  diminu- 
tion of  tension  the  resonance  becomes  deeper  and  clearer — hyperreso- 
nance:  lastly,  when  the  lung  is  markedly  relaxed  and  retracted  the 
note  becomes  actually  tympanitic  in  quality,  with  lowest  pitch. 
Hyperresonance  occurs  also  in  emphysema,  where  the  threefold  con- 
dition of  increased  volume  and  decreased  tension  (loss  of  elasticity) 
of  the  vesicular  tissue  and  the  enlargement  of  the  ribs  contribute  and 
combine  to  produce  the  abnormally  deep,  almost  tympanitic  sound  or 
characteristic  "bandbox"  note. 

The  pitch  of  tympanitic  sounds  varies  according  to  the  appended 
factors.  Of  the  open  tympanitic  sound  the  pitch  is  determined  by: 
(a)  The  size  of  the  communicating  opening;  the  larger  it  is  the  higher 
the  pitch;  (&)  the  volume  of  the  air-containing  cavity;  the  larger  the 
size  the  lower  the  tone;  (c)  the  tension  of  the  walls.,  if  resilient;  the 
greater  the  tension  the  higher  the  pitch. 

Over  closed  cavities  the  pitch  of  the  tympanitic  note  depends  upon : 


94  PHYSICAL    DIAGNOSIS 

(a)  The  volume  of  the  cavity;  (h)  the  tension  of  its  yielding  walls: 
the  same  as  b  and  c  preceding. 

Of  the  two  varieties  of  tympanicity  the  pitch  of  the  open  is  usually 
higher  than  that  of  the  closed;  at  the  same  time  the  open  tone  is 
more  distinctly  drumlike  in  quality. 

The  tympanitic  sound,  whether  open  or  closed  in  quality,  is  never 
found  in  percussing  over  the  normal  chest,  but  as  a  physical  sign 
of  pathological  cavities  of  the  lung  its  occurrence  is  not  at  all  infre- 
quent. However,  good  examples  of  the  characteristics  of  the  open, 
high-pitched  tympanicity  are  heard  in  percussing  or  filliping  the 
larynx  or  the  cheeks,  causing  a  sort  of  "  tubular  "  note.  When  the 
mouth  is  closed  a  lower  pitch  is  detected,  giving  rise  to  the  timbre 
known  as  amphoric  resonance.  Still  graver  tones  are  noticed  in 
eliciting  the  closed  tympanicity  over  the  bowels,  and  gravest  of  all 
over  the  moderately  air-  or  gas-distended  stomach — pronounced  hol- 
lowness. 

When  the  cavities  are  cylindrical  and  communicate  with  the  ex- 
ternal air,  the  pitch  depends  upon  the  length  of  the  tube:  the  longer 
it  is  the  higher  the  tone.  This  may  be  demonstrated  satisfactorily 
by  percussing  lightly  over  a  long-necked  flask,  successively  empty, 
half-  and  nearly  filled  with  water. 

As  regards  the  influence  of  volume  upon  pitch,  there  are  many 
gradations  from  the  loud,  low  stomach  sound  to  the  high-pitched, 
open  tympanitic  note  over  a  small  lung  cavity  (tuberculous). 

The  pitch  of  tympanicity  as  affected  by  the  tension  of  the  cavity 
walls  is  of  some  importance.  Extreme  tension  may  destroy  the  tym- 
panitic quality.  It  has  already  been  remarked  that  when  the  tension 
of  the  lungs  is  greatly  diminished,  whether  pathologically,  as  by  the 
encroachment  of  a  pleuritic  exudation,  or  when  the  lungs  in  a  healthy 
state  are  removed  from  the  body,  the  resonance  becomes  tympanitic. 
Just  so,  on  the  other  hand,  may  the  tension  of  the  walls  be  exagger- 
ated so  that  tympanicity  is  lost  and  clear  nontympanitic  or  lung  sound 
be  produced  in  the  case  of  cavities  or  hollow  organs.  Thus,  we  hear 
the  pulmonary  vesicular  quality  of  sound  in  percussing  over  stomach 
and  intestines  that  are  forcibly  distended  with  air  or  gas.  As  soon 
as  the  internal  pressure  is  relieved  the  tympanitic  character  is  again 
restored.  In  the  living  subject,  therefore,  the  lower  tension  and  pitch 
of  normal  stomach  and  bowels  and  abnormally  relaxed  lung  corre- 
spond; while  the  normally  inflated  lungs  and  abnormally  distended 
gastro-intestinal  canal  correspond  in  possessing  both  higher  tension 
and  higher  pitch,  the  first  group  yielding  tympanitic  sound,  the  other 


PEKCUSSION  95 

nontympanitic  resonance.  In  the  case  of  the  former,  the  air  or  gas 
alone  is  set  into  vibration,  the  flaccid  walls  tending  to  increase  the 
amplitude  of  the  sound  waves  by  reflecting  them;  in  the  latter,  not 
merely  the  contained  air — packed  in  and  condensed,  as  it  were — 
vibrates  to  the  percussion  stroke  as  best  it  may,  but  the  tense  mural 
tissues  also  respond  with  short,  accelerated  waves  of  higher  pitch 
and  change  of  quality  because  of  the  commingling  of  the  vibrations 
of  this  solid  substance.  Instead  of  the  consonance  of  the  reflected 
and  intensified  waves  of  tympany,  we  have  the  more  dissonant,  resist- 
ing, interference  waves  of  the  pulmonary  type  of  resonance.  Enor- 
mously tight  distention  may  give  rise  to  such  inability  of  the  con- 
tained gas  to  vibrate  that  the  possible  clearness  of  sound  due  to  its 
presence  is  quite  neutralized  by  the  vibrations  of  its  containing  walls 
only;  hence  the  dull  sound  of  solid  tissue,  with  corresponding  eleva- 
tion of  pitch. 

The  pitch  of  dull  sounds  varies  according  to  the  degree  of  density 
of  the  tissue  percussed ;  the  denser  it  is,  the  duller  or  flatter  the  quality, 
the  higher  the  pitch.  In  other  words,  pathologic  diminution  of  air- 
containing  tissue  is  indicated  whenever,  in  percussing  over  any  region 
of  the  chest,  for  example,  in  either  infraclavicular  space,  the  pitch 
is  found  to  be  distinctly  elevated  as  compared  with  the  same  region 
on  the  other  side,  or  with  adjacent  normal  vesicular  substance;  in 
fact,  the  detection  of  airless  tissue  abnormally  located,  by  the  evidence 
of  dulness,  is  made  essentially  by  the  attribute  of  comparatively  higher 
pitch. 

In  a  general  way  it  may  be  stated,  that  any  pathologic  condi- 
tion which  adds  dulness  to  or  impairs  the'  clearness  of  a  resonant 
or  tympanitic  sound,  thereby  raises  its  pitch  and  also  reduces  its 
loudness. 

Normally,  the  proximity  of  the  heart  and  liver — airless  organs — to 
the  borders  of  the  lungs  muffles  or  deadens  slightly  the  clearness 
obtained  in  percussing  over  the  latter,  and  this  is  recognized  by  the 
slight  rise  in  pitch — relative  dulness. 

It  should  be  remembered,  however,  that  a  high-pitched  sound  is 
not  necessarily  a  dull  one,  as  it  may  be  tympanitic  from  a  small 
vomica  (cavity)  in  the  lung,  or  resonant,  as  over  the  tip  of  the  lung 
apex  posteriorly,  above  the  scapula. 

Attention  may  be  called  here  to  the  very  slightly  higher  pitch 
elicited  on  percussing  over  the  right  lung  as  compared  with  the  left, 
due  to  the  difference  of  density  which  causes  the  normal  vocal  fremi- 
tus  to  be  a  trifle  more  marked  here  also  (see  Palpation). 


96  PHYSICAL    DIAGNOSIS 

(D)  Duration. — This  attribute — the  length  of  time  a  sound  can 
be   heard — is  the  least  important  of  the  four,   but  in  combination 
with  the  others  may  be  a  very  helpful  element  in  determining  small 
variations  of  sound  characteristics. 

The  sound  vibrations  developed  by  percussing  over  normal  lung 
remain  audible  distinctly  longer  than  over  the  liver  or  heart,  and 
least  so  in  striking  the  thigh.  Thus  duration  varies  directly  will) 
intensity  and  clearness;  the  louder  and  clearer  the  tone,  also  the 
lower  the  pitch,  the  longer  the  duration,  the  less  loud,  duller,  higher- 
pitched  sounds  having  relatively  short  duration. 

The  normal  pulmonary  resonance  being  full  and  clear,  loud,  and 
grave  in  pitch,  has  long  duration.  The  sonorous  tympanitic  sound 
is  likewise  lengthily  audible,  depending  upon  the  volume  and  pitch ;  if 
produced  by  percussing  a  large,  dilated,  gas-filled  stomach,  the  dura- 
tion will  be  greater  than  the  lung  resonance.  Obviously,  too,  the  dura- 
tion of  a  relatively  dull  note  is  longer  than  an  absolutely  dull  or  flat 
sound;  the  conditions  which  influence  the  production  of  persistent 
sounds  are  the  same  as  those  which  affect  their  clearness,  loudness, 
and  graveness,  and  vice  versa. 

(E)  Sensation  of  Resistance. — This  has  been  alluded  to  under 
palpatory  percussion.     While  percussing  over  air-containing  organs, 
as  the  stomach  and  lungs,  and  then  over  an  airless  organ,  as  the  liver, 
a  feeling  of  resistance  by  the  striking  as  well  as  the  pleximeter  finger 
is  noticed  over  the  latter.     Thus,  clear  sounds  are  associated  with 
slight  resistance,  and  dull  sounds  with  a  decided  resistance. 

This  sign  bears  a  direct  ratio  to  pitch;  that  is,  as  the  pitch  rises 
the  resistance  is  felt  to  increase.  It  depends  upon  the  degree  of 
capacity  of  the  underlying  parts  to  vibrate; 
upon  their  consistence  and  thickness.  Nor- 
mally, the  sense  of  yielding  or  elasticity  is 
much  greater  over  the  interspaces  than  over 

the    ribs     OT     SCapula>.        Path- 

ologically,  lung  conditions 
producing  dead  or  dull 
sounds,  as  large  consolida- 

Tympanitic  tone 

Volume  and  duration  tions  or  large  pleuritic  exu- 

FIG.   23.— DIAGRAMMATIC    SKETCH    OF    THE      dations     and     the     like,     have 
RELATIONS  OF  THE  ELEMENTS  OF  TONE.        ^  -.       .,       ..  ., 

(Le  Fevre.)  decreased  vibrating  capacity, 

and   consequently   offer   great 

r<v-i-!;ince  to  the  percussing  fingers;  this  is  intensified  if  there  is  ac- 
companying increased   tension   of   the  chest   wall,   while    conditions 


PERCUSSION  97 

which  augment  the  amount  of  air,  provided  mural  tension  is  not 
increased  at  the  same  time,  give  greater  resiliency  and  less  resistance. 
To  parallel  the  associated  attributes  of  sound  as  they  occur  for 
the  recognition  of  the  two  extremes  of  gross  physical  conditions  and 
changes  of  the  bodily  organs,  the  following  is  easily  apprehended: 

Air-containing  Structures.  Airless  or  Solid  Structures. 

Sounds :          Clear  in  quality,  Dull,  dead,  or  flat. 

Loud  in  intensity,  Not  loud. 

Low  in  pitch,  High-pitched. 

Long  in  duration,  Short. 
Sensation  of 

resistance :  Sligh  t,  absent,  Marked. 

PERCUSSION   SOUNDS  OF  THE  NORMAL  CHEST 

Regional  Variations 

Prerequisite  to  any  practical  knowledge  and  judgment  concerning 
pathologic  alterations  of  the  percussion  sounds,  and  of  the  regional 
and  anatomical  limits  over  which  they  are  audible,  is  a  retentive  and 
ready  knowledge  of  the  normal  boundaries,  and  of  the  anatomic  and 
physiologic  differences  of  sound  over  the  principal  areas  of  the  healthy 
lungs. 

Technic  of  Percussion  of  the  Lungs. — Using  the  most  serviceable 
— the  finger — method,  we  begin  in  front  to  percuss  the  apices  in  the 
SUPRACLAVICULAR  SPACES,  carefully  comparing  one  side  with  the  other 
repeatedly,  at  the  end  of  or  during  a  full  inspiration  and  a  forced  ex- 
piration. The  strokes  should  be  delivered  with  moderate  force.  It 
will  be  noticed  that  the  apex  of  the  right  lung  is  not  so  resonant  as  the 
left ;  that  is,  the  pitch  over  the  right  apex  is  a  trifle  higher  than  over 
the  left.  This  corresponds  to  the  slightly  exaggerated  but  normally 
greater  vocal  fremitus  over  the  right  side. 

A  slightly  less  resonant  sound  over  the  left  apex,  as  from  a  small 
tubercular  consolidation,  might  not  differ  in  quality  from  that  elic- 
ited over  the  normal  right  apex;  hence,  the  discovery  of  slightly 
decreased  resonance  (and  elevated  pitch)  over  the  left  top  is  pre- 
sumptive evidence  of  the  presence  of  a  pathologic  enfeeblement 
there.,  even  when  these  signs  are  no  more  pronounced  than  over 
the  right  corresponding  region.  If,  instead  of  the  slight  normal, 
there  occurs  a  decided  lessening  of  the  resonance  over  the  right 
apex,  then  its  pathologic  indication  is  clear,  although  its  occur- 


98  PHYSICAL    DIAGNOSIS 

rence  on  the  left  side  would  be  all  the  stronger  evidence  of  disease 
there. 

The  predominating  frequency  with  which  the  apex  of  either  lung 
becomes  the  seat  of  an  incipient  tuberculous  process  necessitates  espe- 
cial care  in  the  percussion  of  presumably  early  cases.  Familiarity 
with  the  physical  signs  of  the  apical  region  and  their  variations  in 
health  is  the  indispensable  prerequisite  in  detecting  incipient  disease. 
As  pointed  out  by  Minor,  Auld,  Landolfi,  and  many  others,  the  reso- 
nant area  above  the  clavicles  should  be  carefully  outlined  compara- 
tively with  and  without  respect  to  deep  inspiration. 

Early  indications  of  abnormalities  are  (1)  failure  of  the  upper 
line  of  resonance  on  one  or  the  other  side  to  ascend  during  a  deep 
inspiration;  (2)  a  lowering  of  the  upper  line  of  resonance,  in  whole 
or  in  part,  as  compared  with  that  of  the  opposite  side;  and  (3)  indis- 
tinct definition  of  the  upper  or  outer  line  of  resonance. 

Landolfi  (Semaine  Medicale,  XXVI,  No.  11),  of  Naples,  has 
indicated  six  points  (demonstrated  by  subsequent  autopsies)  where 
percussion  is  liable  to  reveal  impaired  resonance  suspicious  of  an 
incipient  tuberculous  process.  Point  1  is  1  cm.  below  the  clavicle, 
at  the  junction  of  the  inner  third  and  the  outer  two-thirds.  Point  2 
is  the  same  distance  above  the  clavicle,  on  the  same  vertical  line. 
Point  3  is  at  the  intei  section  of  the  acromiomastoid  line  with  a 
line  uniting  Point  1  with  Point  4.  The  latter  point  is  in  the  center 
of  a  line  drawn  from  the  acromion  to  the  spinous  process  of  the 
second  dorsal  vertebra,  and  is  the  only  point  on  the  back.  Point  5 
is  1  cm.  below  the  center  of  the  clavicle,  and  Point  6  is  just  inside 
the  acromion  and  above  the  acromiocervical  line.  He  points  out 
that  the  less  the  difference  between  the  results  of  light  and  heavy 
percussion  at  Point  6  the  greater  the  probability  of  a  lesion  of  the 
apex. 

Near  the  inner  end  of  the  clavicle  the  vesicular  resonance  becomes 
a  little  tympanitic  because  of  the  proximity  of  the  trachea.  The 
pitch  is  slightly  lower  at  the  acromial  than  at  the  sternal  end  of  the 
clavicle. 

Immediate  percussion  of  the  CLAVICLES  produces  a  clear  sound 
of  the  mixed  pulmonary  and  bone  elements.  As  the  character  of  the 
resonance  will  vary  with  the  size  and  shape  of  the  bone,  the  true 
condition  of  the  lung  underneath  is  not  always  indicated.  The  irregu- 
lar and  calloused  form  of  a  previously  fractured  clavicle  would  be 
particularly  misleading  in  either  direct  or  comparative  observations. 

On  the  STERNUM  the  note  is  clear  and  deeply  resonant,  with  a 


PERCUSSION  99 

slightly  tympanitic  quality  over  the  manubrium,  on  account  of  the 
nearness  of  the  trachea  and  roots  of  the  bronchi.  The  resonance 
down  to  the  third  rib  is  fully  vesicular;  below  that  it  is  a  trifle  dull 
because  of  the  adjacent  influence  of  the  heart  (right  ventricle)  and 
liver  (left  lobe).  As  pointed  out  before,  though  lung  tissue  does  not 
lie  directly  behind  the  sternum,  the  clear  sound  is  produced  by  the 
vibrations  setting  into  acoustic  activity  the  neighboring  lung.  Along 
the  left  edge  of  the  sternum,  between  the  fourth  and  sixth  ribs,  the 
heart,  uncovered  by  lung,  renders  a  dull  percussion  sound. 

Next  the  IXFRACLAVICULAR  SPACES  are  percussed,  comparing  the 
first  and  second  interspaces  on  each  side,  using  moderately  strong 
strokes.  Here  we  obtain  the  typical  lung  or  vesicular  resonance — the 
standard  region  for  each  individual — again  noting,  however,  the  very 
slightly  duller,  higher-pitched,  shorter  sound  on  the  right  side.  Thus 
individual  chests  have  their  individual  degrees  of  resonance,  the  nor- 
mal, regional  deviations  from  which  must  be  estimated  with  the  best 
judgment  possible  for  each  person,  adopting  the  note  elicited  in  the 
second  interspace,  below  the  middle  of  the  clavicle,  as  a  sort  of  indi- 
vidual resonant  keynote. 

The  vesicular  quality  is  less  distinct  in  percussing  near  the  ster- 
num on  account  of  the  muffled  tympanitic  modification  due  to  the 
adjacent  sternum  and  bronchotracheal  tubes.  From  the  midclavicu- 
lar  (mammillary)  line  outward  the  resonance  is  a  trifle  less  clear 
and  deep. 

Three  explanations  are  usually  given  for  the  slightly  duller  pul- 
monary resonance  on  the  right  side,  any  one  or  all  of  which  may 
cause  the  difference:  (1)  The  greater  thickness  of  the  chest  wall 
consequent  upon  the  greater  development  of  the  pectoral  muscles  on 
the  right  side.  This  difference  may  be  less  apparent  in  the  chests  of 
left-handed  persons,  but  not  necessarily  always  so.  (2)  An  explicit 
reason  is  found  in  the  fact  that  there  is  a  different  anatomical  arrange- 
ment of  the  bronchial  tubes,  that  on  the  right  side  being  larger,  and 
situated  more  superficially  and  higher  up;  this,  with  a  bunch  of 
medium-  and  small-sized  bronchial  branches  occupying  space  that  on 
the  left  side  is  filled  with  air-vesicles,  gives  an  amount  of  broncho- 
vesicular  tissue  sufficient  to  elevate  the  pitch  slightly  but  perceptibly, 
the  tubes  adding  an  element  of  tympany,  the  extra  muscular  and 
connective  tissue  of  their  firm  walls  an  element  of  dulness.  (3) 
Finally,  the  fact  that  the  right  lung  rests  upon  a  solid  organ — the 
liver — may  influence  the  resonance  enough  to  impair  its  vesicular 
clearness,  loudness,  and  depth  of  pitch. 


100  PHYSICAL   DIAGNOSIS 

MAMMARY  BEGIONS. — Beginning  at  the  third  interspace  and  per- 
cussing down  the  nipple  line  on  the  right  side,  we  find  the  pulmonary 
resonance  becoming  gradually  relatively  dull,  just  noticeable  in  the 
fourth  interspace  owing  to  the  increased  thickness  of  the  chest  wall 
from  adipose  tissue  and,  especially  in  women,  the  mammae,  besides 
the  approach  to  the  dome  of  the  liver  and  the  thinning  of  the  inter- 
posed layer  of  lung,  until  the  fifth  interspace  is  reached,  where  the 
thin  border  of  lung  is  only  sufficient  to  prevent  the  relative  dulness 
from  being  absolutely  dull,  as  it  is  in  the  sixth  interspace  with  light 
percussion,  and  more  decidedly  in  the  seventh  and  eighth  interspaces 
with  heavier  percussion.  Strong  strokes  are  necessary  where  the  chest 
wall  seems  to  be  thickest  in  order  to  bring  out  the  acoustic  evidence 
of  the  subjacent  air-cells. 

On  the  left  side,  slight  relative  dulness  begins  in  the  third  inter- 
space, in  the  parasternal  line,  with  moderately  strong  plexor  blows. 
Here  there  is  but  a  thin  layer  of  lung  resting  over  the  upper  and 
outer  borders  of  the  heart,  and  gliding  to  and  fro  with  inspiration 
and  expiration.  In  the  fourth  and  fifth  interspaces  pulmonary  reso- 
nance is  entirely  replaced  by  absolute  cardiac  dulness,  readily  de- 
tected with  light  percussion  blows.  Outside  the  left  mammillary  line, 
as  far  as  the  anterior  axillary  line,  and  in  the  fifth  and  sixth  inter- 
spaces, there  is  a  degree  of  resonance  a  little  less  pronounced  than 
over  the  space  above,  at  times  modified  slightly  at  the  lower  and 
outer  parts  by  the  mingling  of  stomach  tympany.  Of  course,  the 
cardiac  dulness  and  gastric  tympany  are  both  less  distinct  when  the 
inflated  lung  is  percussed  at  the  end  of  a  full  inspiration. 

Over  the  right  inframammary  region  we  meet  with  absolute  liver 
dulness  from  the  sixth  rib  down  to  the  costal  border;  in  approaching 
the  latter,  however,  the  percussion  strokes  must  not  be  given  with 
much  force  or  the  tympanitic  sound  of  the  large  intestine  below  will 
be  elicited  and  overshadow  the  dulness  before  the  edge  of  the  liver 
has  actually  been  reached.  The  sensation  of  resistance  here  is  quite 
marked. 

On  the  left  side  the  sound  obtained  is  mainly  tympanitic  on  ac- 
count of  the  stomach;  if  not  distended  with  air  or  gas,  the  stomach 
sound  may  be  a  muffled  tympany,  or  if  after  a  meal  percussion  is 
made  here,  the  note  will  be  dull,  this  quality  being  contributed  to 
by  the  adjacent  left  lobe  of  the  liver  above  and  to  the  right,  and  the 
spleen  to  the  left.  This  tympanitic  area,  bounded  above  by  the  pul- 
monary resonance  at  the  sixth  rib,  below  by  the  slightly  higher-pitched 
tympanicity  of  the  splenic  flexure  of  the  colon,  and  to  the  right  and 


PERCUSSION  101 

left  by  the  hepatic  and  splenic  dullnesses  just  mentioned,  is  called 
often  "  Traube's  semilunar  space." 

The  axillary  regions  may  be  percussed  next.  On  both  sides  the 
vesicular  resonance  is  clear  and  full  down  to  the  seventh  rib  in  the 
midaxillary  line,  but  slightly  impaired  in  the  seventh  interspace.  In 
both  infra-axillary  regions  below  the  eighth  rib  the  sounds  are  dull; 
a  little  duller  on  the  right  side  because  of  the  liver;  while  on  the 
left  side  there  is  part  tympany  and  part  dulness  on  account  of  the 
proximity  respectively  of  the  stomach  and  spleen. 

Finally,  we  percuss  the  posterior  regions  of  the  thorax  with  the 
subject  leaning  forward  a  little,  the  arms  folded,  and  all  muscular 
contractions  avoided  as  much  as  possible. 

SUPRASCAPULAR  SPACES. — Forcible  percussion  here  yields  pulmo- 
nary resonance  of  less  intensity  and  higher  pitch  than  in  front,  owing 
to  the  thickness  of  the  intervening  tissues  and  the  very  small  volume 
of  underlying  air-cells.  The  tip  of  each  apex  is  just  below  the  flat 
surface  of  the  supraspinous  region,  and  an  important  point  in  search- 
ing for  the  evidences  of  incipient  tuberculosis.  The  border  of  the 
trapezius  muscle  forms  the  dividing  line  of  two  conjoined  triangles 
within  which  the  anterior  and  posterior  aspects  of  the  lung  apices 
may  be  examined.  The  lower  side  of  the  anterior  triangle  is  formed 
by  the  clavicle,  of  the  posterior  by  the  spine  of  the  scapula,  both 
triangles  converging  at  the  point  of  the  shoulder. 

In  the  scapular  regions  strong  percussion  is  required  also  to  bring 
out  even  moderately  the  resonant  tone,  the  thickness  of  bone  and 
muscle  interfering  most  decidedly  with  clearness,  loudness,  and  grave- 
ness  of  pitch,  as  compared  with  the  resonance  obtained  in  the  infra- 
clavicular  region,  and  resisting  most  markedly  the  plexor  and  plexim- 
eter  fingers.  The  spine  of  the  scapula  responds  with  a  high-pitched 
osteal  sound. 

The  resonance  in  the  interscapular  region,  while  better  than  over 
the  supra-  and  infraspinous  areas,  is  still  weak,  relatively,  owing  to 
the  firm  and  thick  musculature  near  the  vertebral  column.  In  the 
upper  portion  the  trachea  may  superadd  a  tympanitic  quality  to  the 
resonance. 

The  infrascapular  regions  emit  the  best  resonance  posteriorly  dur- 
ing a  moderate  strength  of  percussion.  From  the  angles  of  the  scapu- 
lae to  the  ninth  interspaces  the  note  is  clear  and  of  distinct  resonant 
quality,  although  a  little  less  so  on  the  right  side  because  of  the  larger 
muscular  development  in  most  people,  and  the  subjacent  solid  liver. 
With  heavy  percussion  relative  dulness  may  be  elicited  as  high  as  the 


102  PHYSICAL    DIAGNOSIS 

eighth  rib.  Below  the  tenth  rib  absolute  liver  dulness  is  noted.  On 
the  left  side,  forcible  blows  may  impart  a  tympanitic  character  from 
the  stomach  and  colon  beneath,  or  a  dull  modification  near  the  pos- 
terior axillary  line  because  of  the  spleen. 

To  summarize :  The  pulmonary  resonance  is  heard  most  typically 
in  the  left  infraclavicular  region;  anteriorly,  it  is  better  heard  over 
the  upper  half  of  the  chest;  posteriorly,  over  the  lower  half;  it  is 
more  distinct  and  full  anteriorly  than  laterally  (axilla?),  and  more 
so  laterally  than  posteriorly. 

Regional  Differences  of  Pitch. — These  vary  with  the  conditions 
of  volume  and  tension  of  air-containing  tissue,  and  of  chest  thickness 
and  density  already  instanced.  They  practically  mark  the  areas  of 
different  degrees  of  clear  quality  before  given,  for  it  is  by  pitch  more 
than  any  other  attribute  that  we  note  the  regional  changes  and  points 
of  transition  from  one  sound  characteristic  to  another. 

Thus,  a  rising  gradation  of  pitch  may  be  perceived  in  passing  over 
the  following  anterolateral  regions :  grave  pitch  in  Traube's  semilunar 
space  (overdistended  stomach) ;  axillary  region  (stomach  and  lung 
sound);  the  second  interspace;  the  supraclavicular  space;  the  third 
interspace  (left) ;  the  fourth  interspace  (left) ;  the  seventh  and  eighth 
interspaces  in  the  right  midclavicular  line  (liver). 

It  is  important  to  repeat  in  other  and  more  general  words  that 
since  comparative  percussion  must  habitually  be  practised  in  the  de- 
tection of  disease,  the  normal  variations  of  sound  over  symmetrical 
parts  of  the  chest  on  the  two  sides  should  constantly  be  borne  in  mind. 
The  most  marked  dissimilarity  in  healthy  individuals  is  in  the  right 
and  left  mammary  regions — the  neighborhood  of  the  heart.  Further 
than  this,  it  is  only  needful  to  remember  especially  the  slightly 
clearer  note  over  the  left  as  compared  with  the  right  apex  of  the 
lungs,  and  generally,  the  fact  that  elsewhere  on  the  right  side  the 
corresponding  situations  are  a  trifle  less  clear  and  intense  than  on 
the  left. 

Variations  Due  to  Age  and  Sex. — The  percussion  sound  differs 
normally  according  to  age.  In  children,  with  their  thin,  elastic  chest 
walls,  the  note  is  more  resonant,  graver  in  pitch,  louder,  and  of  longer 
duration  than  in  aged  persons;  the  quality  is  peculiarly  soft  and 
clear.  The  stiffness  of  the  thorax  and  hardness  of  the  ribs  in  old  age, 
together  with  senile  relaxation  of  the  lungs,  causes  the  resonance  to 
be  less  pronounced  and  higher  in  pitch.  This  difference  is  apt  to  be 
all  the  more  marked  the  thicker  the  fleshy  coverings  of  the  chest 
wall  and  the  greater  the  diminution  of  lung  volume.  On  the  other 


PERCUSSION  103 

hand,  the  change  in  pitch  will  be  counteracted  somewhat  by  emacia- 
tion of  the  chest  and  senile  atrophy  of  the  pulmonary  parenchyma. 

As  to  sex,  we  usually  find  the  resonance  to  be  more  distinct  in 
women  than  in  men,  especially  in  the  upper  regions,  owing  to  the 
superior  costal  breathing  and  less  firm  and  massive  bony  thorax. 

Topographic  Percussion 

Determining  the  Boundaries  of  the  Lungs  and  Adjacent  Organs. 
TECHNIC. — As  for  diagnostic  purposes  it  is  important  to  ascertain 
the  size  of  the  lungs,  the  percutory  determination  of  their  borders  on 
the  surface  of  the  thorax  is  a  matter  calling  for  careful  practise. 
The  position  of  the  lung  boundaries,  as  affected  by  physiologic  and 
pathologic  mobility,  and  the  encroachments  of  other  organs  or  of 
new  growths,  are  also  involved. 

CONDITIONS. — In  order  that  the  borders  of  the  lungs  (or  of  any 
of  the  viscera)  may  be  outlined  topographically  by  percussion,  it  is 
necessary,  in  the  first  place,  that  they  be  sufficiently  parietal ;  secondly, 
that  they  yield  sounds  differing  from  the  surrounding  and  adjacent 
tissues.  Hence,  the  boundaries  between  two  organs  giving  forth  abso- 
lutely dull  sounds  cannot  be  recognized,  as  between  the  inferior  border 
of  the  heart  and  the  left  lobe  of  the  liver,  or  between  the  left  lower 
border  of  the  heart  and  a  left-sided  pleural  effusion.  But  the  adjacent 
borders  of  an  air-containing  and  an  airless  organ  are  the  more  readily 
determined;  thus,  the  lung-heart  and  the  lung-liver  and  the  lung- 
spleen  boundaries  are  found.  Again,  we  can  tell  an  organ  giving  a 
clear,  tympanitic  sound  from  one  that  causes  a  deadened  sound,  as 
stomach  from  spleen  or  liver;  and  yet  again,  clear  sounds  differing 
from  each  other  in  quality  on  the  one  hand,  and  pitch  on  the  other; 
thus,  lung  from  stomach  in  the  case  of  the  former,  and  stomach  from 
bowel,  or  large  from  small  bowel,  in  the  case  of  the  latter. 

METHOD. — In  determining  the  boundaries  by  percussion  we  usu- 
ally percuss  from  clear  to  dull,  no  matter  what  the  organ  under  ex- 
amination, as  the  modifications  of  slight  deadening  are  more  quickly 
detected  as  affecting  a  resonance  than  those  of  clearness  in  passing 
from  a  dull  area.  Approach  to  an  organ  is  made  along  lines  per- 
pendicular to  its  supposed  borders,  with  the  pleximeter  finger  conse- 
quently parallel  to  such  borders.  We  percuss  on  these  lines  until 
the  sound  changes,  striking  at  intervals  of  an  inch  or  an  interspace 
approximately  at  first,  then  repeating  carefully  and  closely  so  that 
we  are  certain  that  at  a  given  point  lung  ends  and  another  organ 


104  PHYSICAL    DIAGNOSIS 

begins;  this  point  may  be  marked  with  a  blue  pencil,  ink,  or  iodine 
dot  or  dash.  Similar  markings  made  along  the  boundaries  so  de- 
termined may  be  joined  by  a  continuous  line,  which  will  then 
represent  as  nearly  as  possible  the  surface  outline  of  the  lungs,  for 
example. 

Accuracy  in  topographic  percussion  is  better  assured  if  it  be  made 
the  rule  to  percuss  very  lightly  along  the  borders  of  the  organ  whose 
location  and  size  we  are  essaying  to  define. 

Practising  the  contrary  of  this,  by  forcible  strokes  near  the  edge 
of  organs,  as  of  lung  near  the  cardiac  or  hepatic  borders,  must  obvi- 
ously cause  dulness  to  be  elicited  before  one  actually  has  passed 
beyond  the  lung  boundary;  or  again,  by  strong  percussion  over  the 
lower  border  of  the  liver,  the  adjacent  underlying  intestine  is  set  in 
vibration,  and  a  tympanitic  tone  is  obtained  before  the  edge  of  the 
liver  has  been  reached. 

Furthermore,  as  the  volume  of  air-containing  tissue  of  the  lung 
borders  is  very  slight,  the  sound  must  have  little  intensity  and  dis- 
tinctive clearness;  slight  differences  of  sound  on  the  border-line  are 
better  perceived  if  the  sounds  themselves  are  slight  (Vierordt). 

NORMAL  PERCUSSION  LIMITS  OF  THE  LUNG. — The  normal  ana- 
tomic boundaries  have  already  been  described,  but  it  is  not  possible 
to  define  them  throughout  by  percussion,  as  the  differences  of  sound 
are  often  slight,  particularly  at  the  left  inferior  border,  near  the 
stomach,  the  tympanitic  sound  of  which  frequently  mingles  with 
pulmonary  resonance  above  the  anatomic  lung  boundaries  to  confuse 
the  real  line  of  transition. 

Also,  the  absence  of  the  condition  of  adjacent  differences  of  sound 
prevents  us  from  delimiting  the  anterior  borders  of  the  lungs  behind 
the  sternum  because  of  their  parallel  proximity,  and  the  exaggerated 
uniformity  of  resonance  produced  by  the  characteristic  osteal  tone  of 
the  sternum  itself. 

The  determinable  percussion  outlines  of  the  lungs  are,  then,  the 
superior,  cardiopulmonary,  and  inferior. 

(1)  The  Apices. — In  healthy  persons,  during  ordinary,  quiet  res- 
piration, the  vesicular  resonance  extends  about  2  to  4  cm.  (f  to  If  in.) 
above  the  upper  border  of  the  clavicle.  With  a  deep  inspiration  the 
apical  resonance  in  the  supraclavicular  spaces  is  clearer  and  fuller, 
and  more  extensive  in  all  directions.  The  determination  of  the  upper 
borders  of  the  lungs  is  important  because  of  the  evidence  of  tuber- 
culous deposit  or  pleuritic  adhesion  which  the  discovery  of  unilateral 
depression  or  shrinking  of  the  apex  indicates. 


PERCUSSION 


105 


In  children  suffering  with  membranous  croup  or  extensive  broncho- 
l>neunionitis,  the  accompanying  collapse  of  the  apical  vesicles  which 
may  ensue  prevents  one's  getting  resonance  above  the  clavicles. 


FIG.  24. — SHOWING  THE  RELATIVE  RESONANCE  OF  VARIOUS  PORTIONS  OF  THE  AN- 
TERIOR SURFACE  OF  THE  THORAX.  Horizontal  lines  =  pulmonary  resonance. 
Vertical  lines  =  tympanitic  resonance  of  trachea  and  stomach.  Oblique  lines  = 
impaired  resonance  or  moderate  dulness  due  to  mammary  glands,  liver,  heart, 
and  spleen.  Solid  shading  =  absolute  dulness  due  to  liver  and  heart.  (Butler.) 

Temporarily  during  attacks  of  bronchial  asthma,  and  constantly 
in  cases  of  emphysema,  the  superior  border  of  the  lungs  is  found 
on  percussion  to  be  higher  than  normal  with  expiration,  owing  to 
the  difficult  and  delayed  and  incomplete  expulsion  of  the  tidal  air 
as  the  thoracic  expiratory  movement  takes  place.  At  the  same  time 
the  sound  has  a  vesiculotympanitic  quality. 

(2)  The  Lung-Heart  Boundary. — This  is  determinable  only  by 
light  percussion,  because  of  the  small  volume  of  lung  at  its  border.  It 
is  found  to  follow  along  the  fourth  rib,  from  the  sternum  to  a  little 
external  of  the  parasternal  line,  whence  it  passes  downward  and  out- 
ward to  the  sixth  rib  in  the  midclavicular  line,  forming  the  upper 
and  outer  boundaries  of  the  superficial  cardiac  dulness  due  to  the 
exposed  part  of  the  right  ventricle,  and  producing  a  corresponding 


106  PHYSICAL   DIAGNOSIS 

zone  of  impaired  lung  resonance  (relative  dulness)  about  the  width 
of  an  interspace  beyond  the  edge  of  the  lung. 

When  the  anterior  border  of  the  lung  is  physiologically  distended 
with  a  full  inspiration,  or  pathologically  from  emphysema,  the  en- 
croachment it  makes  upon  the  cardiac  dulness  diminishes  its  area, 
and  in  the  case  of  a  marked  emphysema  may  obliterate  it  entirely. 

On  the  other  hand,  the  percutory  determination  of  retracted  lung 
border  may  indicate  tuberculous  or  fibroid  disease,  pleural  effusion 
with  collapse  of  lung,  or  displacement  outward  of  this  border  by  the 
pressure  of  a  pericardial  effusion  or  of  an  enlarged  heart;  the  area 
of  absolute  cardiac  dulness  is  correspondingly  increased. 

(3)  The  Lower  Borders. — In  front,  the  percussion  limit  of  the 
lung  does  not  extend  quite  as  far  down  on  the  right  as  on  the  left 
side,  the  right  coming  low  as  the  inferior  border  of  the  fifth  rib, 
the  left  to  the  superior  border  of  the  sixth. 

On  the  right  side,  in  percussing  down  to  the  lung-liver  boundary, 
a  relatively  dull  sound  is  detected  in  the  nipple  line  at  the  fifth  rib 
approach,  which  passes  into  absolute  or  superficial  liver  dulness  in 
the  sixth  interspace.  The  narrow  zone  of  deep  or  relative  liver  dul- 
ness extends  around  the  chest  to  the  spinal  column,  between  the 
seventh  and  eighth  ribs  in  the  axillary  region  and  between  the  ninth 
and  tenth  ribs  in  the  scapular  line. 

There  may  be  an  extension  more  or  less  beyond  an  interspace 
farther,  due  to  emphysematous  enlargement  of  the  lung.  Also,  if  the 
lower  borders  are  higher  than  normal,  we  must  think  of  the  possi- 
bility of  fibroid  retraction,  causing  apparent  or  spurious  enlargement 
of  the  liver,  or  a  pushed-up  diaphragm  due  to  meteorism,  ascites, 
large  abdominal  tumors,  especially  of  the  liver  itself,  and  paralysis 
of  the  phrenic  nerve. 

Posteriorly,  the  lower  border  of  the  lung  may  be  pushed  up 
by  a  pleural  effusion,  the  dulness  produced  by  which  extending 
upward  continuous  with  that  of  the  liver  joins  a  modified — more 
or  less  tympanitic — resonance  where  the  partially  collapsed  lung  is 
reached. 

On  the  left  side,  percussion  downward  to  the  inferior  border  at 
the  sixth  rib  in  the  mammillary  line  is  resonant,  but  along  the  border 
to  the  midaxillary  line  it  is  slightly  admixed  with  the  tympanitic 
element — the  lung -stomach  boundary.  At  the  eighth  rib  and  mid- 
axillary  line  we  note  slightly  duller  note  of  the  lung-spleen  boundary. 
Finally,  near  the  spine,  we  define  less  distinctly  the  lung-kidney 
boundary,  at  the  level  of  the  tenth  interspace  or  eleventh  rib. 


PERCUSSION"  107 

DIFFERENCES  DUE  TO  AGE. — In  young  children  the  lower  borders 
of  the  lungs  are  from  one-half  to  one  inch — about  an  interspace — 
higher  than  for  the  normal  person  of  middle  age;  in  the  old,  the 
borders  extend  a  rib  or  interspace  lower,  the  lungs  increasing  in  size 
with  advancing  years.  For  the  same  reason,  the  lung-heart  boundary 
leaves  less  heart  area  uncovered  by  lung. 

In  estimating  the  percussion  limits  of  the  lower  borders  of  the 
lungs,  allowance  must  also  be  made  for  their  physiologic  displace- 
ments as  produced  by  the  respiratory  or  active  mobility  and  the 
postural  or  passive  mobility. 

(1)  Respiratory  Mobility. — In  quiet  breathing  the  lower  borders 
extend  only   about  f  in.    (1   cm.)    into  the  inferior  complementary 
pleural  sinus  (q.  v.),  from  1£  to  1|  in.  (3  to  4  cm.)  in  deep  inspira- 
tion in  the  midaxillary  line,  and  about  f  to  1^  in.  (2  to  3  cm.)  in  the 
midclavicular  and  scapular  lines.     According  to  Weil,  in  deepest  ex- 
piration the  lung  borders  move  a  little  less  than  the  same  extent 
above  the  average  location.     The  mobility  of  the  lung  edges  where 
they  overlap  the  heart  is  also  a  trifle  less  than  inferiorly. 

(2)  Postural  Mobility. — The   respiratory    displacement   depends 
upon  the  position  of  the  body.     In  the  dorsal  position  the  anterior 
lower  edge  of  the  lung  moves  f  in.  (2  cm.)  lower  than  in  the  vertical 
position.     On  turning  from  the  back  to  the  (either)  side,  while  re- 
cumbent, the  lower  border  descends  as  much  as  4  in.  (10  cm.)  in  the 
midaxillary  line,  on  the  uppermost  side,  although  a  mobility  of  but 
2  in.  on  the  part  of  the  uppermost  lung  is  more  common. 

The  pathologic  alterations  of  the  topographic  pulmonary  outlines 
(already  referred  to)  will  be  considered  also  in  connection  with  their 
relations  to  the  abnormalities  of  active  and  passive  mobility,  after  the 
description  of  the  diagnostic  significance  of  pathologic  percussion 
sounds  given  in  the  next  chapter. 


CHAPTER   V 

PERCUSSION   (Concluded) 

THORACIC  PERCUSSION  SOUNDS  (Concluded) 

ABNORMAL  PERCUSSION  SOUNDS  DUE  TO   DISEASES  OF  THE 
LUNGS   AND   PLEURA 

Their  Physical  Explanation  and  Diagnostic  Significance 

WHILE  a  certain  and  constantly  improving  skill  in  technic,  and 
perception  and  judgment  in  regard  to  the  normal  and  regional  varia- 
tions of  the  lung  sound  are  prerequisites  in  this  method  of  examina- 
tion, it  is  the  main  object  to  seek  for  the  abnormal — either  the  detec- 
tion of  a  normally  occurring  sound  in  an  abnormal  location  or  of 
alterations  of  normal  sounds  in  any  location — and  then  to  know  the 
physical  and  pathologic  conditions  which  give  rise  to  them,  with  their 
diagnostic  interpretation. 

The  immediate  aim  and  result  of  percussion  is  to  determine  the 
density  of  the  subjacent  parts.  Inferentially,  that  means,  first,  the 
determination  of  any  increase  or  diminution  of  the  normal  quantity 
of  air  present  in  the  lungs;  and,  secondly,  the  delimitation  of  the 
site  and  area  within  which  the  change  has  occurred,  including  the 
differentiation  of  pathologic  lung  boundaries  from  adjacent  air- 
containing  and  airless  organs. 

Thoracic  percussion  is  also  an  important  aid  in  ascertaining  ab- 
normal physical  conditions  of  the  pleural  membranes  and  sacs. 

Abnormal  sound  over  the  lungs  may  indicate  not  only  the  pres- 
ence or  absence  and  the  volume  of  air,  but  changes  in  the  quan- 
tity, density,  and  tension  of  the  pulmonary  tissue,  as  will  be  shown 
later. 

There  may  be  areas  over  both  lungs  which  yield  percussion  sounds 
different  from  the  normal,  hence  the  presence  of  bilateral  disease, 
or  they  may  be  found  only  on  one  side,  in  unilateral  disease; 
finally,  there  may  be  but  one  or  two  small  areas  of  local  in- 
volvement. 

108 


PERCUSSION  109 

A.  Dulness:  Impaired  or  Deadened  Resonance 

Pathologic  dull  sounds  may  be  comparatively  slight,  in  relation  to 
the  corresponding  region  on  the  other  side,  whence  the  terms  im- 
paired, diminished,  or  deficient  resonance,  or  slight  dulness;  or  there 
may  be  moderate,  decided,  or  marked  dulness',  lastl}7,  when  the  part 
gives  forth  a  sound  like  that  over  the  thigh  or  over  a  solid  organ,  it 
is  termed  absolutely  dull,  dead,  or  fiat. 

When  dulness  is  caused  by  disease  within  the  lung,  the  condi- 
tion is  intrapulmonary;  when  caused  by  pleural  affections,  extra- 
pulmonary. 

Intrapulmonary  Conditions. — Resonance  is  deadened  here  by  the 
deposit  or  infiltration  of  airless  tissue  in  the  lung,  causing  consolida- 
tion and  compression. 

We  recall,  also,  besides  the  change  in  the  quality  of  the  percussion 
note,  the  diminished  intensity,  raised  pitch,  and  lessened  duration. 

(1)  SLIGHT  DULNESS. — This  occurs  where  the  air  vesicles  are 
blocked  or  consolidated  in  small,  lobular  areas.  The  location  and 
number  of  such  areas  of  consolidation  may  be  of  aid  in  diagnosis. 
Thus,  if  located  in  front,  at  or  near  the  apices,  and  single  in  occur- 
rence, it  usually  indicates  tuberculous  deposit  there;  if  lower  down, 
posteriorly,  and  multiple  in  number,  a  bronchopneumonitis  is  usually 
indicated.  Again,  early  tuberculosis  is  generally  one-sided,  while  the 
latter  is  bilateral. 

In  order  that  the  dulness  may  be  detected  over  small  consolida- 
tions, light  percussion  strokes  are  necessary,  so  as  to  avoid  setting 
into  vibration  the  closely  surrounding  open  air  vesicles.  Where  sev- 
eral small  areas  of  consolidation  exist  closely  adjacent  to  each  other, 
the  intervening  vesicular  tissue,  being  relaxed,  elicits  a  high-pitched 
tympanitic  sound,  more  or  less  muffled  according  to  the  nearness  and 
largeness  of  the  consolidated  areas. 

In  early  tuberculosis  of  one  apex,  very  frequently  the  first  and  only 
physical  evidence  of  apical  consolidation  is  manifested  by  diminished 
resonance  a  little  behind  and  below  the  border  of  the  trapezius  muscle, 
in  the  supraspinous  region  on  the  affected  side. 

Whether  the  unilateral  consolidation  be  in  the  supraclavicular  or 
supraspinous  region,  the  resulting  slight  or  relative  dulness  is  more 
easily  detected  if  located  on  the  left  than  the  right  side,  because  of 
the  slight  normal  impairment  of  resonance  on  the  right  bide;  so  that 
a  degree  of  dulness  over  the  left  apex  equal  to  that  over  the  right 
justifies  the  suspicion  of  disease  on  the  left,  while  the  degree  of 


110  PHYSICAL    DIAGNOSIS 

dulness  on  the  right  side  sufficient  to  indicate  consolidation  there 
must  be  greater  than  the  normal  difference  between  the  two  sides; 
in  other  words,  a  slightly  more  advanced  stage  of  deposit.  Perforce, 
dulness  that  is  distinctly,  though  slightly,  greater  on  the  left  than 
on  the  right  side  is  all  the  more  positively  significant  of  disease  on 
the  left  side. 

Whenever  both  apices  are  diseased,  and  comparison  of  one  si<l«; 
with  the  other  is  thus  inadmissible,  the  fact  is  demonstrated  by  com- 
paring the  sound  with  the  resonance  over  the  adjacent  parts  lower 
down  on  the  same  side. 

In  persons  with  sedentary  habits  and  occupations  who  are  poor 
breathers,  and  in  those  who  may  be  thus,  or  by  heredity,  predisposed 
to  pulmonary  tuberculosis,  the  finding  of  slight  impairment  of  reso- 
nance over  both  apices,  disappearing  after  a  few  forced  respirations, 
is  evidence  that  such  individuals  do  not  ordinarily  use  their  apices, 
which  become  more  or  less  collapsed  for  want  of  air. 

Small  patches  of  slight  dulness  on  percussion,  in  the  interscapular 
region  near  the  spinal  column,  may  indicate  the  presence  of  tubercu- 
lous enlarged  bronchial  glands,  or  of  accumulations  of  exudation 
within  the  bronchial  tubes. 

Hemorrhagic  infarct  of  the  lung  may  be  inferred  where  a  small 
area  of  slight  dulness  is  discovered,  especially  over  the  middle  and 
lower  lobes  of  the  right  lung,  after  the  sudden  onset  of  respiratory 
distress  where  mitral  valvular  heart  disease  exists.  The  greater  the 
exclusion  of  air,  and  its  area  being  not  less  than  1|  in.  (4  or  5  cm.) 
in  diameter,  the  better  the  dulness. 

Besides  the  occurrence  of  bronchopneumonitis,  small  areas  of  im- 
paired resonance  over  the  lower  lobes  posteriorly  may  be  caused  by 
atelectasis,  as  from  the  obstructive  bronchial  closures  of  childhood, 
and  by  thickened  and  dilated  bronchi,  and  solid  growths  on  or  near 
the  surface  of  the  lung. 

(2)  MODERATE  DULNESS. — This  is  present  when  there  is  moderate 
infiltration  of  the  lung,  as  a  small  portion  of  a  lobe.  It  is  found, 
for  example,  in  tuberculous  disease  of  the  apices  when  the  consolida- 
tion has  progressed  beyond  the  first  stages  of  just-recognizable  deposit. 
It  is  also  obtained  over  scattered  areas  of  the  bronchopneumonitis, 
acute  and  subacute  or  catarrhal,  characteristic  of  old  people,  espe- 
cially as  a  complication  of  influenza,  these  patches  being  large  enough 
to  make  the  circumscribed  areas  of  dulness  unmistakable  enough  so 
that  the  surrounding  zones  of  relaxed,  tympanitic  lung  do  not  markedly 
modify  their  tonelessness.  These,  with  the  patches  of  atelectasis  which 


PEKCUSSION  111 

often  accompany  them,  are  usually  found  over  the  lower  lobes  pos- 
teriorly. 

Moderate  dulness  is  present  also  posteriorly  at  the  base  in  the 
congestion  of  hypostasis  of  weak  heart,  particularly  when  some  exu- 
dation into  the  alveoli  has  taken  place  (pulmonary  edema),  as  in 
those  who,  from  prolonged  and  exhausting  sickness,  have  had  to  remain 
most  of  the  time  in  a  dorsal  position. 

Abscess,  gangrene,  large  hemorrhagic  infarcts,  and  tumors  of  the 
lung,  and  thick-walled  bronchiectatic  cavities  partially  filled  with 
exudate,  also  give  rise  to  moderate  percussion  dulness. 

Here  should  be  considered  the  important  relation  between  the 
strength  of  the  percussion  stroke  and  the  depth  of  location  of  partial 
lobar  consolidations  of  the  lung. 

The  positiveness  with  which  a  partial  consolidation  of  the  lung 
is  revealed  by  the  relative  or  moderate  dulness  elicited  depends  upon 
whether  it  is  near  enough  to  the  chest  wall  to  be  discovered  with  light 
or  medium  percussion  force,  or  whether  it  is  so  far  beneath  the  surface 
that  it  can  be  discovered  only  with  the  most  forcible  strokes  permis- 
sible by  the  tolerance  of  the  patient. 

In  other  words,  to  put  it  in  an  inductive  and  practical  way,  if 
with  a  comparatively  light  percussion  stroke  a  small  or  medium-sized 
area  of  relative  dulness  is  found  which,  with  stronger  strokes,  becomes 
louder  and  resonant,  it  betokens  the  presence  of  a  superficial,  sub- 
pleural,  airless  mass  so  thin  that  heavy  strokes  penetrate  through  it 
to  set  into  vibration  the  air-containing  vesicles  below  it.  If,  however, 
over  a  given  area,  light  percussion  blows  yield  clear,  resonant  sounds 
of  normal  quality  for  that  region,  while  a  decided  strengthening  of 
the  blow  over  the  same  space  yields  a  marked  relative  dulness,  it 
means,  obviously,  that  there  is  a  deeply  seated  consolidation,  with 
sufficient  intervening  normal  or  relaxed  lung  to  prevent  any  but  power- 
ful percussion  blows  from  reaching  it  so  as  to  give  the  muffled,  less 
loud,  and  higher-pitched  note. 

A  parietal  patch  of  consolidation  may  be  recognized  by  dulness 
on  light  percussion  if  not  smaller  than  about  1£  in.  in  diameter; 
larger  consolidations  may  be  discovered  by  forcible  percussion  if  not 
more  deeply  seated  than  about  2|  to  3  in.  (6  to  7  cm.). 

(3)  ABSOLUTE  DULNESS. — This  is  obtained  when  a  large  portion 
of  the  lung,  as  a  whole  lobe,  or  even  the  whole  lung,  has  been  ren- 
dered practically  airless,  solid.  It  is  typically  and  commonly  present 
in  acute  lobar  pneumonitis,  where  the  alveoli  of  one  or  more  lobes  are 
filled  with  a  firm,  fibrinous,  inflammatory  exudate  in  the  stage  of 


112 


PHYSICAL    DIAGNOSIS 


hepatization  (liver-like  condition).  And  yet  the  sound  is  rarely  as 
completely  deadened  as  the  thigh  sound,  but  may  frequently  have  a 
slight  admixture  of  the  tympanitic  element  because  of  adjacent  por- 
tions of  merely  congested,  relaxed  lung.  The  sensation  of  resistance 
is  decidedly  increased. 


Heightened  pitch  or 
impaired  resonance 


Moderate  dulness 


Slight  dulness 


FIG.  25. — SHOWING  THE  VARIATIONS  OF  LESSENED  RESONANCE  DUE  TO  THE  PRESENCE 
OF  CONSOLIDATIONS  IN  THE  LUNG  OR  FLUID  IN  THE  PLEURAL  CAVITY.     (Butler.) 

If,  in  addition  to  the  vesicular  tissue,  the  bronchial  tubes  within 
the  consolidated  area  are  at  the  same  time  clogged  up  with  the  exu- 
dation (massive  pneumonia),  or  if,  as  often  happens,  there  is  marked 
pleuritic  exudation,  either  fibrinous  or  serofibrinous,  the  dulness  be- 
comes extreme  or  flat  as  a  result  of  such  complications,  with  high 
pitch,  short  duration  of  sound,  and  intense  resistance.  As  the  lower 
lobes  are  by  far  the  most  frequently  attacked  in  pneumonitis,  the 
dulness  is  generally  limited  to  the  infrascapular  and  axillary  regions, 
and  more  often  on  the  right  than  the  left  side. 

Absolute  dulness  is  also  present  over  extensive  areas  of  tubercular 
consolidation,  with  thickening  of  the  pleura,  over  the  upper  parts 
of  the  chest. 

Rarely,  absolute  dulness  may  be  elicited  because  of  large  pulmo- 
nary abscesses  and  mediastinal  tumors  of  considerable  size  pushing 
the  lung  aside  and  touching  the  chest  wall. 


PEBCTTSSION  113 

The  extent  of  the  area  of  dulncss  in  acute  lobar  (croupous)  pneu- 
monitis  may  coincide  with  the  normal  limits  of  the  lobe  affected, 
topographically;  but  as  a  pulmonary  lobe,  when  completely  consoli- 
dated, is  more  often  considerably  increased  in  bulk,  the  area  of  dul- 
ness  is  correspondingly  enlarged.  Thus,  posteriorly  the  dulness  may 
extend  upward  almost  to  the  apex  without  the  upper  lobe  being  in- 
volved, and  on  the  left  side,  with  pneumonitis  of  the  lower  lobe,  the 
encroachment  of  dulness  downward  upon  the  semilunar  stomach  space 
is  noted  in  the  diminished  tympanitic  area  of  the  latter. 

Finally,  a  peculiar  but  characteristic  "  wooden "  quality  of  per- 
cussion dulness,  occurring  in  the  chests  of  certain  old,  emaciated,  but 
"  wiry  "  individuals  who  have  had  one  or  more  attacks  of  pneumoniHs 
or  pleuritis,  may  be  found,  usually  affecting  nearly  all  of  one  side. 
I  have  seen  such  cases  more  often  in  miners  and  veterans  of  the  Civil 
War.  The  sensation  of  resistance  is  much  increased.  The  condition 
indicated  is  that  of  marked  fibroid  thickening  in  the  lung;  hence  the 
terms  fibroid  phthisis  and  chronic  interstitial  pneumonia.  Some 
thickening  of  the  overlying  pleura  is  generally  present  also. 

Extrapulmonary  Conditions. — The  most  important  of  these  is 
pleuritic  exudation.  Marked  dulness  or  flatness  accompanies  the 
presence  of  liquid  effusion  in  the  pleural  sac,  and  also  of  thickening 
of  the  pleura  due  to  plastic  fibrinous  deposit  of  sufficient  amount. 
Even  slight  thickening  of  the  pleura  may  be  detected  by  moderate 
dulness,  and  increased  resistance  or  hardness  of  "  feel,"  on  account 
of  the  contiguous  nearness  of  the  exudate  to  the  intercostal  tissues. 
Otherwise,  the  intensity  of  the  deadness  of  sound  depends  upon 
the  degree  of  thickening  which  may  accompany  the  presence  of 
fluid  lower  down  or  remain  after  the  removal  of  the  latter  by  absorp- 
tion or  aspiration  with  the  hollow  needle.  Considerable  dulness 
over  the  apices  in  early  tuberculosis  is  frequently  due  to  pleural 
thickening. 

The  amount  of  liquid  exudate  necessary  to  produce  appreciable 
dulness  at  the  base  of  the  chest  is  about  400  c.c.  This  gravitating 
into  the  lowest  and  most  superficial  part  of  the  complementary  pleural 
sinus  in  the  posterolateral  region,  and  having  a  thickness  of  about 
three-quarters  of  an  inch,  may  be  recognized  by  light  percussion,  the 
dulness  extending  not  more  than  two  or  three  fingers'-breadth  above 
the  posterior  lower  limits  of  the  lung.  And  when  the  layer  measures 
more  than  two  or  three  inches  in  depth,  ordinary  percussion  elicits 
absolute  dulness,  any  further  augmentation  of  fluid  causing  extension 
of  dulness  from  the  base  to  the  upper  level. 
10 


114 


PHYSICAL    DIAGNOSIS 


As  the  quantity  of  liquid  increases  the  area  of  dulness  spreads 
laterally  and  upward,  then  to  the  front,  and  still  higher,  so  that  when 
the  pleural  sac  is  half  or  more  than  half  filled  we  find  the  dulness 
extending  from  the  vertebral  column  around  to  the  sternum,  and  from 
the  lower  borders  of  the  ribs  to  the  upper  intercostal  spaces,  though 
most  decidedly  flat  at  the  base.  Pleural  effusion  of  the  right  side  is 


DULNESS  OF  FLUID 
REPLACING  NOR- 
MAL TYMPANITIC 
RESONANCE  OF 
STOMACH  IN 
TRAUBE'S  AREA 


FIG.  26. — SHOWING  THE  DULNESS   DUE  TO   FLUID   IN  THE   LEFT  COMPLEMENTARY 
(REFLECTED)  PLEURA.     (Butler.) 

recognized  by  an  extension  upward,  apparently,  of  the  liver  dulness. 
On  the  left  side,  a  diminution  of  the  normal  area  of  tympany  in 
Traube's  half-moon-shaped  space,  more  pronounced  than  in  cases  of 
lobar  pneumonitis;  and  the  discovery  of  a  band  of  dulness  reaching 
upward  in  the  anterior  axillary  region  from  the  eighth  rib  to  the 
sixth  or  higher,  is  characteristic  of  the  presence  of  fluid  here. 

The  upper  level  of  a  liquid  exudation  usually  extends  higher  pos- 
teriorly than  anterolaterally  in  patients  confined  to  bed,  the  fluid  being 
free  to  move;  while  in  those  who  are  able  to  be  about,  as  in  some 
subacute  and  chronic  cases,  the  level  is  maintained  nearly  horizontal 
round  the  chest. 

The  dulness  obtained  in  percussing  over  a  pleural  effusion  is  the 
result  both  of  the  intervention  of  a  nonresonant  substance  and  of  the 
simultaneous  proportionate  expulsion  of  air  from  the  adjacent  com- 
pressed lung.  What  resonance  is  obtained  even  near  the  upper  level 
of  the  exudate  is  very  shallow  because  of  the  small  volume  of  air 
present. 


PERCUSSION  115 

Grocco's  Paravertebral  Triangle  in  Pleural  Effusions. — This  sign 
is  of  importance  in  the  diagnosis  of  one-sided  pleural  effusions.  It 
was  stated  by  Grocco,  in  1902,  that  in  case  of  a  pleural  effusion  on 
one  side,  the  other  side  presented  a  triangular  area  of  dulness  over  the 
back  of  the  thorax.  The  inner  line  of  this  triangle  runs  along  the 
spine,  the  lower  line  coincides  with  the  lower  margin  of  the  resonance 
for  3  to  10  cm.,  and  the  outer  line  of  the  triangle  follows  an  oblique 
line,  uniting  at  an  acute  angle  with  the  first  line  on  a  level  with 
the  top  of  the  effusion.  This  paravertebral  dulness  was  always  more 
marked  Avhen  the  effusion  was  on  the  right  side.  The  proof  of  the 
genuineness  of  the  triangular  dulness  is  its  disappearance  when  the 
patient  lies  on  the  side  of  the  effusion,  and  its  reappearance  imme- 
diately he  sits  up  or  lies  upon  the  sound  side.  When  the  pleura  is 
much  distended  the  mobility  of  the  fluid  is  reduced,  but  the  para- 
vertebral triangle,  while  not  absent,  becomes  less  in  height  with  the 
change  to  the  lateral  posture. 

Marked  dulness  occurring  posterolaterally  at  the  base  on  both  sides 
is  commonly  produced  by  hydrothorax,  or  a  dropsical  transudation 
into  the  pleura.  However,  the  amount  of  fluid  is  rarely  the  same 
on  the  two  sides.  The  upper  limits  of  dulness  vary  also  with  posture, 
although  the  mobility  is  apt  to  be  a  little  more  noticeable  than  where 
there  is  inflammatory  pleuritic  exudation  present. 

A.  band  of  dulness  at  the  base  sharply  passing  into  a  large  area 
of  tympanitic  sound  above  is  significant  of  hydropneumothorax  or 
pyopncumothorax.  Here  the  mobility  with  changing  of  posture  is 
most  free,  as  evinced  by  the  prompt  changing  of  the  boundaries  of 
dulness  due  to  the  rapid  gravitation  of  the  serum  or  pus,  as  the 
case  may  be. 

Finally,  in  rare  cases,  a  dull  note  may  be  caused  by  an  intense 
pneumothorax,  the  air  distending  the  pleural  sac  to  the  utmost,  thus 
abolishing  elasticity  and  resonance  completely,  and  by  tumors  of  the 
pleura,  the  latter  giving  rise  to  irregularly  situated  and  outlined  areas 
of  deadness. 

The  diagnostic  value  of  regional  dulness  may  be  summarized  by 
the  following  simple  statements:  (a)  Apical  dulness,  in  the  great 
majority  of  instances,  means  tubercular  consolidation,  rarely  pneu- 
monitis,  gangrene,  or  new  growths;  (fo)  dulness  in  the  interscapular 
region  indicates  usually  tuberculous  bronchial  enlargement  or  tuber- 
culous infiltration  of  the  posterior  borders  of  the  lungs,  while  on  the 
left  side  it  may  mean  aneurism  of  the  descending  aorta;  (c)  dulness 
over  the  lower  lobes — that  is,  in  the  lower  axillary,  and  especially 


116  PHYSICAL   DIAGNOSIS 

in  the  infrascapular  regions — points  to  pneumonic  consolidation  or 
pleural  effusion  most  commonly,  although  it  may,  in  rare  cases,  be 
produced  by  infarct,  gangrene,  and  tumors,  and  when  not  extreme 
in  quality  hypostatic  congestion,  edema,  or  collapse  (atelectasis)  of 
the  lung  may  be  inferred. 

B.  Exaggerated  or  Abnormally  Clear  Resonance;  Ilyperresonance; 
Vesiculotympanitic  Resonance 

Increase  in  the  clearness  and  fulness  of  vesicular  resonance,  gener- 
ally or  locally,  indicates  an  increase  in  the  amount  of  air  in  the  luu.^s. 
or  its  presence  in  the  pleural  sac  (hyperresonant  tone).  This  sound 
has  the  quality  of  normal  resonance,  but  the  intensity  is  louder,  the 
pitch  lower,  and  the  duration  longer  than  in  health,  and  the  resist- 
ance to  the  percussing  fingers  is  less  apparent. 

(1)  Slightly  exaggerated  resonance  is  usually  found  over  a  local 
increase  in  the  volume  of  air,  as  over  a  sound  lobe  adjacent  to  onu 
that  is  consolidated,  the  healthy  part  performing  extra  work  to  com- 
pensate for  the  crippled  area. 

(2)  Moderately  exaggerated  resonance  is  characteristic  in  healthy 
young  children,  with  their  thin  and  elastic  chest  walls.     Unilateral  I  ij, 
it  occurs  in  percussing  over  the  overdistended,  unaffected  lung  that 
is  temporarily  doing  double  labor  because  of  consolidation  or  com- 
pression  of    the    opposite    lung.      This    functional    enlargement    of 
one  lung  is  often  called   "  vicarious "   or   acute   compensatory   em- 
physema. 

In  pathologic  or  permanent  overdistention  of  both  lungs  in  true 
emphysema,  the  exaggeration  of  resonance  in  the  early  stages  of  the 
disease  is  but  moderate.  In  extreme  anemia,  also,  probably  on  account 
of  the  lessening  of  the  relative  quantity  of  blood  in  the  lungs,  a  certain 
intensification  of  the  resonance  may  be  elicited. 

If,  with  the  vesicular  dilation,  the  tension  is  greatly  increased, 
as  in  some  cases  of  compensatory  emphysema,  the  pitch  may  be  slightly 
raised  because  of  the  dominance  of  that  factor  over  the  increase  in 
size  of  the  air-cells. 

(3)  Hyperresonance. — Abnormally  marked  clear,  deep,  and  loud 
resonance  is  typically  heard  over  the  whole  chest  of  one  having  well- 
developed   emphysema.     The   emphysematous  sound   has   been  well 
designated  the   "  bandbox  note."     Its  quality  approaches  nearly   to 
that  of  the  tympanitic.     It  is  accounted  for  by  the  double  pathologic 
condition  of  increased  volume  of  air  from  permanently  dilated  vesi- 


PERCUSSION"  117 

cles  and  decreased  tension  because  of  the  weakened  elasticity  of  the 
vesicular  substance,  both  causing  a  marked  deepening  of  the  pitch. 
Hyperresonance  is  also  heard  typically  in  pneumotliorax,  usually  over 
one  side. 

(4)  Vesiculotympanitic  Resonance.  SKODAIC  RESONANCE. — Al- 
though essentially  synonymous  with  the  quality  of  hyperresonance, 
the  sound  first  described  by  Skoda,  and  later  designated  vesiculo- 
tympany  by  the  American  clinician,  Austin  Flint,  Sr.,  requires  sepa- 
rate consideration  because  of  its  usage  in  these  terms,  and  the  fact 
that  it  occurs  in  special  conditions  with  characteristics  of  a  slightly 
Ji if/her  pitch  and  sometimes  more  tympanitic  attribute  than  the  loud 
and  grave  note  of  hyperresonance. 

The  discrimination  may  be  made  in  this  wise :  if  the  sound  elic- 
ited is  that  of  loud  and  low-pitched  exaggerated  resonance  on  both 
sides,  or  on  the  greater  part  of  one  side,  bilateral  enlargement  of  lung, 
as  in  senile  emphysema,  or  unilateral  diffuse  or  closed  pneumothorax 
are  inferred;  but  if,  with  increased  intensity  of  note  the  pitch  is  at 
the  same  time  higher  than  over  an  adjacent  part  on  one  side  of  the 
chest,  particularly  if  the  quality  is  almost  tympanitic,  the  Skodaic 
resonance  heard  indicates  a  partial  relaxation  of  the  underlying 
vesicular  tissue,  as  over  an  upper  lobe  when  the  lower  is  solidified 
in  the  second  stage  of  pneumonitis,  or  just  above  the  level  of  the 
fluid  of  a  pleural  effusion.  In  the  latter  case  the  Skodaic  resonance 
is  typically  in  evidence  when  the  quantity  of  exudation  is  sufficient  to 
fill  about  one-third,  one-half,  or  even  two-thirds  of  the  pleural  sac, 
so  as  to  float  the  lung  upward  and  diminish  its  volume  and  intra- 
vesicular  tension  without  completely  compressing  it.  In  percussing 
from  below  upward  posteriorly,  the  transition  from  the  pleuritic  dul- 
ness  to  a  tympanitic  hyperresonance  at  the  level  of  the  angle  of  the 
scapula,  for  example,  is  quite  characteristic;  and  yet,  as  compared 
with  the  sound  over  the  unaffected  lung  opposite,  the  pitch  is  a  trifle 
higher,  even  taking  into  consideration  the  slight  elevation  of  pitch 
from  increased  tension  which  the  overacting  normal  lung  in  a  state 
of  compensatory  emphysema  is  laboring  under. 

Vesiculotympany  in  the  neighborhood  of  the  heart  may  point  to 
localized  diminished  pulmonary  tension  due  to  a  pericardial  effusion, 
or,  less  commonly,  to  the  encroachment  of  a  much-enlarged  heart. 
Likewise,  decreased  tension  of  the  lower  borders  of  the  lungs  due 
to  a  very  high  position  of  the  diaphragm  from  great  abdominal 
enlargements  may  be  demonstrated  by  the  Vesiculotympanitic  note 
obtained. 


118 


PHYSICAL    DIAGNOSIS 


C.  Tympanitic  Sound  and  Us  Variations 

The  tympanitic  sound  is  not  heard  over  normal  lung  tissue ;  there- 
fore its  presence  always  indicates  disease  of  the  structure  directly 
beneath  the  percussing  ringers, 'or  quite  adjacent  to  the  region  per- 
cussed. 

The  pathologic  conditions  giving  rise  to  tympany  are  seldom  of 
such  size  as  to  cause  the  pitch  to  be  as  low  as  that  of  the  normal 
pulmonary  resonance.  Broadly  speaking,  the  comparatively  low- 
pitched  and  louder  (although  less  grave  and  intense  than  the  vesicu- 


TYMPANITIC  (SKODAIC)  RESONANCE 
CRACKED-POT  RESONANCE 

WlNTRICH'S    PHENOMENON    (AT    TIMES) 

PECTORILOQUY  (RARELY) 


FIG.  27. — SHOWING  CERTAIN  PERCUSSION  AND  AUSCULTATORY  FINDINGS  ABOVE 
CONSOLIDATIONS  OR  EFFUSIONS.     (Butler.) 

lar  resonance)  tympanitic  sounds  are  produced  by  absolutely  relaxed 
lung,  and  large  pulmonary  and  pleural  cavities,  from  whatever  specific 
cause;  the  higher-pitched  by  small  cavities  filled  with  air,  and  small, 
circumscribed  areas  of  dilated  or  relaxed  vesicular  tissue. 

(1)  Tympany  of  Relaxed  Lung. — As  an  occasional  exception  to 
the  preceding  general  statement,  a  case  of  such  marked  emphysematous 
enlargement  coupled  with  extreme  lowering  of  pulmonary  tension  may 
be  met  in  which  the  tympany  exhibits  very  low  pitch  and  pronounced 
loudness  of  tone  all  over  the  chest. 


PEKCUSSION  119 

Tympany  is  to  complete  retraction  of  the  lung  what  vesiculotym- 
pany  is  to  partial  relaxation.  In  the  former  condition  the  vesicles  are 
in  a  state  of  elastic  equilibrium,  as  when  the  lungs  are  removed  from 
the  body  with  their  size  reduced  from  the  state  of  collapse  and  the 
absence  of  the  intravesicular  inspiratory  tension. 

When  the  cause  of  the  relaxation  resides  within  the  lung,  the  tym- 
pany  is  said  to  be  due  to  immediate  relaxation;  this  occurs  in  the 
first  (congestive)  and  third  stages  of  lobar  pneumonitis  and  in  edema 
of  the  lungs,  the  diminished  tension  being  the  result  of  capillary 
engorgement  (first  stage),  the  presence  of  fluid  and  air  in  the  vesi- 
cles (third  stage),  or  of  transuded  fluid  and  air  (edema).  The  tym- 
pany  in  these  cases  is  slightly  dull  and  of  moderate  pitch,  according 
to  the  volume  of  air  present.  A  small  area  of  high-pitched  tympan- 
icity  may  be  due  to  lax  intervening  air-containing  tissue  between  a 
tubercular  or  bronchopneumonitic  deposit  and  the  surface. 

Mediate  relaxation  of  lung  is  produced  by  some  extrapulmonary 
cause  in  the  pleural  sac,  interfering  'with  the  expansion  of  the  lung. 
The  medium  intervening  to  cause  the  retraction  is  most  commonly 
a  large  pleuritic  exudation.  Elastic  equilibrium  of  the  lung  mani- 
fested by  tympany  may  also  occur  from  large  pericardial  effusions  or 
tumors  in  juxtaposition,  from  subphrenic  abscesses,  and  from  great 
abdominal  distention  as  witnessed  in  general  peritonitis. 

On  account  of  the  diminished  size  of  lung,  its  compression  even 
in  some  cases,  so  that  one  percusses  hardly  more  than  a  bunch  of  air- 
containing  bronchial  tubes,  the  tympany  is  invariably  higher  pitched 
than  the  normal  resonance  on  the  unaffected  side,  and  also  because 
of  the  muffling  due  to  the  relative  preponderance  of  tissue  minus  air, 
and  the  dulling  effect  of  the  encroaching  fluid. 

The  occurrence  of  apical  tympany  of  high  pitch,  due  to  early 
tuberculosis,  is  sufficiently  frequent  and  important  practically  to 
justify  reiteration.  That  this  sign  may  be  misleading,  relative  dul- 
ness  being  attributed  to  the  sound  and  really  resonant  apex,  is  evi- 
dently because  any  dulness  to  which  a  group  of  nodules  might  give 
rise  is  masked  by  the  surrounding  relaxed  vesicles  of  the  lung;  hence 
the  diagnostic  value  of  the  most  careful  technic  that  the  true  tympan- 
itic  quality  with  slightly  lower  and  louder  sound  than  over  the  healthy 
apex  may  be  recognized. 

(2)  Tympany  over  Pulmonary  Cavities  (Vomicce;  Caverns). — 
Localized  areas  of  tympanitic  sound,  more  or  less  clear  according 
to  the  conditions  about  to  be  pointed  out,  indicate  usually  air-spaces 
or  cavities  due  to  the  destruction  of  lung  tissue  by  phthisis  (tubercu- 


120 


PHYSICAL    DIAGNOSIS 


losis),  gangrene,  abscess,  actinomycosis,  or   circumscribed  bronchial 
dilation  ( bronchiectasis) . 

The  conditions  which  make  it  possible  to  hear  the  tyrnpanitic  per- 
cussion sound  over  lung  cavities,  and  which  affect  its  clearness  or 
intensity,  especially  its  pitch,  are  the  following:  size,  situation,  com- 


Tympauitic  (trachea 
A        and    bronchi   per- 
cussed      through 
consolidated  lung) 


T>  Tympanitic  or 
amphoric 


Hyperresonant  (distended 
cells) 


Tympanitic  (cavity 
percussed  through 
consolidated  lung) 


1) 


Tympanitic  or  am-    TTI 
phoric 


FIG.  28. — DIAGRAM    SHOWING   THE    PHYSICAL,   CONDITIONS    WHICH    CAUSE    HYPER- 

HESONANCi:  AND  TYMPANITIC  OR  AMPHORIC  PERCUSSION  SOUNDS.       (Butler.) 

munication,   form,  quantity  of   liquid   present,  thickness    (rigidity) 
and  smoothness  of  walls,  condition  of  surrounding  lung  and  pleura. 

As  all  of  these  conditions  are  interrelated,  the  audibility  of  the 
cavity  sound  will  depend  upon  their  combination  rather  than  upon 
any  single  one.  Other  things  being  equal,  however,  to  detect  a  cavity, 
its  size  must  not  be  smaller  than  a  walnut  (1  to  1£  in.  in  diameter), 
and  for  that  size  it  must  lie  near  the  surface.  Consequently,  cavities 
of  the  apex  are  more  easily  discovered  because  necessarily  superficially 
situated,  with  thin  chest  wall  intervening;  over  deep-seated  cavities, 
even  when  of  considerable  size,  only  the  faintest  tyrnpanitic  quality 
may  be  elicited,  if  at  all;  the  apical  region  of  the  chest  wall  being 
naturally  thinner  than  that  over  the  lower  lobes,  covered  as  it  is  with 
thick  dorsal  muscles,  therefore  suffers  more  from  the  general  emacia- 
tion associated  with  the  presence  of  cavities. 


PERCUSSION  121 

The  tympanitic  note  over  a  pulmonary  cavern  is  rarely  so  clear 
or  loud  as  intestinal  tympany,  as  it  is  produced  by  the  vibrations  of 
a  much  smaller  body  of  air. 

The  physical  characteristics  of  tympanitic  resonance  are  more  dis- 
tinct if  the  cavity  communicates  with  a  large  bronchial  tube  open  to 
the  outer  air,  the  sound  reverberations  being  freer  than  when  the 
cavity  walls  are  closed  (open  and  closed  tympanitic  sound).  Besides, 
the  hindrances  to  the  development  of  a  tympanitic  sound,  as  thickened 
cavity  walls  or  intervening  normal  lung  tissue,  weaken  its  distinctive- 
ness  more  as  the  closed  than  as  the  open  variety,  since  it  lacks  the 
additional  vibration  of  the  bronchotracheal  column  of  air. 

The  influence  of  the  shape  of  a  cavity  upon  the  tympanitic  note 
will  be  described  later  under  the  consideration  of  the  mutations  of 
the  pitch. 

If  the  cavity  is  partly  filled  with  liquid,  as  not  infrequently  happens 
temporarily,  the  tympanitic  resonance  becomes  relatively  deadened, 
and  of  course  absolutely  so  if  nearly  or  quite  full. 

Smooth,  thin-walled  cavities  give  forth  a  clearer  tone  of  tympany 
than  those  having  rough,  thick  walls.  The  capacity  of  the  former 
to  vibrate  with  their  contained  air  is  obvious. 

More  or  less  muffling  or  deadening  of  tympany  may  be  caused  by 
percussing  a  cavity  covered  with  thickened  lung  or  pleura.  This  dull 
or  "  boardy "  tympanitic  sound  may  become  absolutely  dull  where 
the  consolidation  or  pleural  thickening  increase  markedly,  and  in  some 
cases  cavity  has  been  revealed  post  mortem  that  during  life  was  over- 
looked because  of  the  great  thickening  between  it  and  the  chest  wall 
preventing  the  penetration  of  the  percussion  vibrations. 

The  conditions  causing  changes  in  the  pitch  of  the  tympani'tic 
sound  over  a  cavity  are  notable. 

(a)  TENSION  OF  ITS  WALLS. — Over  a  cavity  with  lax  walls  the 
tympanitic  sound  is  clear  and  low  in  pitch,  with  a  hollow  or  cavernous 
character.  On  the  other  hand,  cavities  with  firm  or  rigid  and  tense 
walls  produce  a  note  which  is  described  as  amphoric,  equally  clear  and 
almost  metallic  in  resonance,  but  higher  pitched  than  the  other. 

(6)  WINTRICH'S  CHANGE  OP  SOUND. — This  phenomenon  is  a  rise 
in  pitch  and  augmented  loudness  of  the  tympanitic  note  when  the 
patient  opens  the  mouth,  protrudes  the  tongue  a  little,  and  at  the 
same  time  breathes  as  lightly  as  possible.  The  percussion  strokes 
should  not  be  too  strong.  When  the  mouth  is  closed  the  pitch  is 
lower,  and  the  sound  less  distinctly  tympanitic;  the  pitch  is  lower 
still  when  the  nostrils  are  closed.  This  simple  Wintrich's  change  of 


122  PHYSICAL    DIAGNOSIS 

sound  occurs  over  those  cavities  that  communicate  freely  with  one 
of  the  bronchi. 

The  paradoxical  combination  of  louder  and  clearer  tympanitic 
sound  with  higher  pitch  is  not  actually  a  contradiction  of  the  law  of 
physics  that,  other  things  being  equal,  the  lower  the  pitch  the  louder 
is  the  sound ;  but  right  here  is  the  point  of  the  matter,  for  the  physical 
conditions  are  not  equal  during  the  percussion  of  a  cavity  when  the 
mouth  is  opened  and  when  it  is  closed.  In  percussing  over  a  cavity 
communicating  with  the  bronchotracheal  column  of  air,  the  mouth 
being  closed,  the  tympanitic  note  is  comparatively  dull  and  yet  low  in 
pitch,  owing  to  the  confined  reflected  sound-waves  becoming  waves 
of  interference,  and  simultaneously  slower  waves.  When  the  mouth 
is  opened,  however,  since  sound-waves  in  air  travel  longitudinally,  at 
the  instant  of  opening  the  percussion  drives  the  waves  out  with  accel- 
erated velocity,  crowding,  as  it  were,  a  number  of  them  with  some 
friction  through  the  oral  orifice  into  the  more  quiescent  outer  air 
at  the  lips;  the  number  of  sound-waves  per  second  received  into  the 
outer  air  is  thus  greater  than  the  number  sent  out,  and  the  pitch  rises 
(Doeppler's  Principle).  Besides  this,  an  important  contributory 
factor  in  the  elevation  of  the  pitch  on  opening  the  mouth  is  the  en- 
larging of  the  external  orifice  of  the  cavity,  as  it  virtually  becomes 
thereby,  obeying  the  law  that  the  larger  the  orifice  the  higher  the 
pitch. 

It  remains  to  state  that  when  the  mouth  is  opened  during  percus- 
sion, the  mouth-throat  cavity  acts  as  a  resonator  to  the  sound-waves 
expelled  from  the  pathologic  cavity,  the  resulting  consonance  giving 
greater  fulness  and  intensity  to  the  tympanicity. 

In  certain  cases  where  the  tissue  around  the  cavity  is  markedly 
thickened,  the  merest  trace  of  tympany  only  may  be  noticeable  in 
percussing  with  the  patient's  mouth  closed,  while  with  the  mouth 
open  the  unmistakable  signs  of  cavity  are  discovered  in  a  clear, 
tympanitic  sound,  louder  and  higher  in  tone,  by  this  Wintrich's 
method. 

The  change  of  sound  may  be  simulated  by  percussing  over  the 
larynx  or  trachea  while  opening  and  closing  the  mouth;  also  in  tap- 
ping the  cheeks  similarly,  or  by  blowing  between  the  thumbs  of  the 
clasped  hands — as  for  whistling — and  then  suddenly  opening  them. 

Wintrich's  change  of  sound  may  occur  also  in  cases  of  pneumo- 
thorax  in  which  there  is  a  fistulous  communication  of  the  pleura  and 
lung  between  the  pleural  sac  and  a  free  bronchus.  Rarely,  the  phe- 
nomenon may  be  elicited  over  the  upper  lobes  of  the  lungs  in  pneu- 


PERCUSSIOX  123 

monitis  when  the  lower  are  consolidated,  or  when  they  are  collapsed 
by  a  pleural  effusion. 

(f)  INTERRUPTED  WINTRICH'S  CHANGE  OF  SOUND. — This  is  a 
change  in  the  distinctness  of  this  sign,  or  even  in  its  occurrence  at 
all,  by  changing  the  position  of  the  body.  That  is,  in  one  position — 
in  sitting,  for  example — the  bronchus  leading  to  the  cavity  is  open, 
and  the  sound  tympanitic,  while  in  the  other — lying  down — the  bron- 
chus dips  beneath  the  surface  of  the  liquid  secretion,  is  thus  closed, 
and  the  sound  is  either  faintly  tympanitic  or  dull;  these  manifesta- 
tions may  be  reversed  for  the  same  postures.  Such  behavior,  though 
rarely  met  with,  when  it  is  becomes  positive  evidence  of  the  presence 
of  a  cavity. 

(d)  GERHARDT'S  CHANGE  OF  SOUND. — This  is  another  variety  of 
altered  pitch  on  changing  the  position  of  the  patient,  nor  frequently 
met  with,  affording  strong  proof  of  the  presence  of  cavity,  however, 
when  elicited.     It  is  indicative  of  large  cavities,  oval  or  elliptical  in 
shape,  and  partly  filled  with  fluid  the  mobility  of  which  with  change 
of  posture  alters  the  form  of  the  air-containing  part  of  the  cavity, 
its  relation  to  the  chest  wall,  and  consequently  its  pitch.     The  latter 
is  lower  when  the  long  diameter  is  horizontal — that  is,  when  the 
cavity  is  of  such  a  form  and  so  situated  that  its  long  diameter  is  about 
parallel  with  the  long  axis  of  the  body,  the  pitch  is  lower  with  the 
patient  in  the  recumbent  position,  the  fluid  gravitating  away  from 
the  chest  wall;  while  when  the  long  diameter  is  vertical,  as  in  the 
sitting  or  standing  posture,  the  sound  becomes  higher,  deadened,  tym- 
panitic, because  the  fluid  is  now  in  closer  contact  with  the  chest  wall ; 
on  the  other  hand,  if  the  cavity's  long  diameter  corresponds  with  the 
anteroposterior  diameter  of  the  thorax,  the  percussion  note  is  lower 
in  the  upright  position,  while  the  column  of  air  is  shortened  when  the 
patient  lies  down,  and  the  pitch  rises. 

Gerhardt's  change  of  sound  may  take  place  over  communicating 
as  well  as  over  closed  cavities.  Change  in  the  tension  of  the  cavity 
wall  may  also  enter  into  the  production  of  these  changes  of  pitch. 

(e)  RESPIRATORY  CHANGE  OF  SOUND  (Friedreich's). — In  this  phe- 
nomenon the  tympanitic  sound  over  a  cavity  becomes  higher  in  pitch 
at  the  height  of  a  deep  inspiration.    It  results  from  increase  of  tension 
of  the  cavity  walls,  the  chest  wall,  and  the  adjacent  lung  substance, 
perhaps.    In  expiration  the  sound  becomes  deeper  or  it  may  disappear, 
especially  during  the  act  of  coughing,  because  of  collapse  or  com- 
pression of  the  cavity  walls.     The  inspiratory  rise  in  pitch  may  be 
partly  due  also  to  the  simultaneous  widening  of  the  glottis. 


124  rilYSICAL   DIAGNOSIS 

(3)  Williams's  Tracheal  Tone  or  "  Resonance." — Closely  allied  in 
character  to  Wintrich's  change  of  sound,  the  conditions  which  give 
rise  to  it  are,  however,  different.  It  is  the  term  applied  to  a  tympan- 
itic  sound  obtained  in  percussing  over  trachea  or  main  bronchus 
(cylindrical  cavity),  the  pitch  being  higher  with  the  mouth  open 
and  lower  and  yet  less  loud  with  the  mouth  closed,  provided  the  con- 
duction of  sound  between  the  bronchotracheal  column  of  air  and 
the  chest  wall  is  facilitated  by  retraction  or  by  consolidation  of  the 
intervening  lung  tissue.  In  the  former  condition,  as  from  the 
shrunken  lung  of  fibroid  phthisis  or  the  collapsed  or  compressed 
lung  of  a  large  pleuritic  exudation,  the  bronchus  is  exposed  by  the 
retracted  anterior  border  of  the  lung;  in  the  latter,  the  bronchial 
tympany,  with  accompanying  change  of  pitch,  is  brought  out  by  the 
better  conduction  of  sound  through  the  hepatized  lung  of  superior 
lobar  pneumonitis  (dulness  with  tympany),  or  of  a  large  tuberculous 
consolidation  of  the  apex;  or,  again,  through  the  condensation  of  a 
lung  by  pleural  effusion  that  does  not  separate  it  too  much  from  the 
front  of  the  chest. 

This  change  of  pitch,  in  opening  and  closing  the  mouth,  is  ob- 
tained normally  in  percussing  over  the  larynx  and  trachea  down  to 
the  bifurcation,  of  the  latter,  at  which  point,  and  over  the  primary 
bronchi,  it  is  lost,  owing  to  the  covering  of  vesicular  lung  substance; 
therefore,  the  detection  of  Williams's  tracheal  tone  here  signifies  a 
pathologic  condition  causing  either  retraction  or  pneumonic  infiltration 
of  the  lung  usually. 

The  phenomenon  is  best  heard,  then,  in  percussing  the  first  and 
second  intercostal  spaces  near  the  sternum.  The  flexibility  of  the 
sternal  ends  of  the  ribs  and  of  the  costal  cartilages  favors  the  produc- 
tion of  the  sound. 

That  the  tracheal  resonance  of  Williams  is  found  more  often  on 
the  left  side  is  due  probably  to  the  greater  length  of  the  left  bronchus. 

To  differentiate  Wintrich's  change  of  sound  from  Williams's  tra- 
cheal tone,  the  following  considerations  may  be  helpful :  ( 1 )  Whether 
the  visible  contraction  is  marked  and  local,  when  it  is  likely  caused 
by  an  apical  cavity ;  absent  or  almost  unilateral  when  it  is  a  tracheal 
tone  from  hepatized  lung  or  shrunken  anterior  border.  (2)  The 
strength  of  stroke  required  to  elicit  the  sign;  the  change  of  pitch 
over  a  cavity  (Wintrich's),  is  easily  obtained  with  light  percussion, 
while  if  a  forcible  stroke  is  necessary,  bronchus  (Williams's)  is  indi- 
cated. (3)  Other  signs  of  cavity  are  more  evident  when  the  change 
of  sound  is  Wintrich's. 


PERCUSSION  125 

A  change  of  sound  similar  to  Williams's  occurring  over  the  upper 
sternum  when  percussed,  where  normally  it  is  absent,  indicates  the 
presence  of  pathologic  thickening  or  new  growth  between  the  trachea 
and  manubrium.  The  cause  may  be  a  mediastinal  fibro-  or  lympho- 
sarcoma,  an  aneurism  of  the  arch  of  the  aorta,  or  a  pericardial  effusion 
displacing  the  heart  upward. 

(4)  Tympanitic  Sound  in  Pneumothorax. — This  is  rarely  met  with, 
and  occurs  in  cases  that  are  circumscribed  and  open;  that  is,  practi- 
cally a  pleural  cavity  walled  in  by  adhesions  and  communicating  with 
the  bronchial  column  of  air  through  a  fistulous  opening  in  the  pleura. 
Hence,  also,  Wintrich's  change  of  sound  may  be  elicited  here.  Should 
the  expiratory  current  of  air  be  prevented  from  escaping  by  the  for- 
mation of  a  valvelike  closure  of  the  pleural  opening,  thus  causing 
the  tension  to  rise  considerably  in  the  interior  because  of  the  suc- 
cessions of  inspiratory  entrance  of  air  while  the  pressure  is  sufficient, 
then  the  note  becomes  hyperresonant,  as  in  the  more  common  diffuse 
or  closed  pneumothorax,  though  not  so  loud,  nor  so  grave  in  pitch. 

D.  Amphoric  or  Metallic  Resonance 

The  amphoric  or  metallic  note  is  fundamentally  tympanitic,  with 
added  overtones  giving  an  echolike  quality  and  prolongation,  or  me- 
tallic clang.  It  is  often  higher  in  pitch  than  the  ordinary  tympanitic 
sound.  While  the  latter  ceases  immediately  after  the  percussion 
stroke,  the  overtones  of  this  amphoric  resonance,  or  metallic  echo, 
die  away  more  slowly.  It  is  like  the  reverberating  prolongation  of 
the  voice  heard  in  speaking  in  a  large,  bare  room  or  empty  hall.  It 
may  be  simulated  by  percussing  or  filliping  the  side  of  an  empty,  or 
nearly  empty,  jar  or  pitcher,  a  large,  hollow  india-rubber  ball,  or 
the  cheeks  with  the  mouth  open. 

Thus,  the  amphoric  sound  is  heard  over  large,  tense  or  rigid,  and 
mooth-walled  cavities  of  the  lung,  superficially  situated,  or  over 
open  pneumothorax.  If  produced  by  a  tuberculous  cavity,  it  means 
that  the  cavity  is  single  or  entire,  and  not  subdivided  by  projections 
or  partitions  of  pulmonary  tissue  that  has  not  disintegrated;  that  it 
is  distended  with  air;  that  it  communicates  more  or  less  freely  with 
a  large  bronchus;  and  that  its  size  is  probably  not  less  than  2|  in. 
(6  cm.)  in  diameter  in  the  direction  in  which  the  percussing  stroke 
is  applied.  The  marked  emaciation  usually  present  in  these  cases 
offers  the  minimum  of  resistance  by  the  chest  wall,  and  so  facilitates 
the  development  of  amphoric  or  metallic  echo. 


126  PHYSICAL   DIAGNOSIS 

The  modifications  of  pitch,  as  in  Wintrich's  change  of  sound,  may 
also  be  elicited  here;  and,  too,  the  variations  due  to  cavities  not 
spherical  in  shape,  as  the  lower  pitch  while  percussing  in  the  direction 
of  the  long  diameter  (Gerhardt's  change). 

Bronchiectatic  cavities  do  not  manifest  the  amphoric  resonance 
because  there  is  less  wasting,  they  are  situated  in  the  lower  lobes  away 
from  the  surface  and  where  the  thicker  posterior  wall  of  the  thorax 
intervenes,  and  because  they  are  too  small  in  size. 

Metallic  sound  is  very  distinctly  heard  over  pneumothorax,  pro- 
vided the  air  contained  in  the  pleura  reaches  a  certain  degree  of  ten- 
sion (not  too  exaggerated).  This  condition  may  be  inferred  if  heard 
over  a  large  area  of  one  side. 

In  order  to  appreciate  amphoric  resonance  more  distinctly,  percus- 
sion with  a  hammer  and  pleximeter  may  be  resorted  to,  with  or  without 
simultaneous  auscultation.  In  combining  the  latter  method,  a  clear, 
metallic  note  is  brought  out  by  placing  the  chest  piece  of  the  stetho- 
scope near  the  pleximeter,  which  is  then  lightly  struck  with  the 
hammer. 

Coin  or  rod-pleximeter  percussion.,  or  the  coin-clinking  test  (Gaird- 
ner),  is  most  effective  in  discovering  pneumothorax.  It  is  practised 
thus:  Two  coins  of  sufficient  size — say  25-  or  50-cent  pieces — one 
applied  flat  to  the  chest,  the  edge  of  the  other  used  as  a  plexor,  are 
used  on  the  anterior  surface  by  an  assistant,  percussing  lightly,  while 
the  examiner  auscults  posteriorly,  or  vice  versa,  either  with  or  without 
a  stethoscope.  Instead  of  coins  the  handle  of  a  hammer  plexor,  or  a 
rod  of  metal  or  pencil,  may  be  used  to  strike  upon  the  pleximeter, 
as  recommended  by  Heubner.  The  presence  of  air  in  the  pleural  sac 
is  indicated  by  a  clear,  ringing,  chiming  sound,  bell-metal  or  anvil- 
like  in  character ;  the  sound  may  be  compared  to  the  tinkle  of  a  small 
bell  (bell-tympany)  or  the  effect  of  striking  an  anvil  with  a  tiny 
hammer.  Comparing  the  two  sides  of  the  chest,  the  absence  of  the 
sign  is  conspicuous  over  the  lung  on  the  unaffected  side,  and  over  the 
lung  on  the  affected  side,  from  which  the  air-space  in  the  pleura 
may  thus  be  sharply  delimited. 

Biermer's  Change  of  Sound. — As  pneumothorax  is  often  accom- 
panied or  followed  by  liquid  effusion  into  the  pleural  cavity,  causing 
pyopneumothorax,  for  instance,  the  region  over  which  amphoric  reso- 
nance may  be  elicited  becomes  gradually  diminished  in  extent,  so 
that  the  amount  of  air  remaining  may  give  rise  only  to  a  tympanitic 
sound  on  percussion,  the  metallic  overtones  disappearing  entirely. 

On  changing  the  posture  of  patients  suffering  with  pyo-  or  sero- 


PERCUSSIOX  127 

(hydro-)  pneumothorax,  the  pitch  of  the  note  changes,  being  lower  or 
higher  according  as  the  long  diameter  of  the  cavity  is  rendered  longer 
or  shorter,  respectively,  as  the  fluid  gravitates  over  the  diaphragm  or 
upon  the  back,  the  patient  sitting  or  lying  down  (so  Biermer).  On 
the  other  hand,  however,  many  clinicians  have  noted  the  change  to 
be  reversed  in  some  cases;  that  is,  the  diameter  may  be  shortened 
while  the  patient  is  erect  and  lengthened  while  recumbent,  with  cor- 
responding change  from  higher  to  lower,  respectively.  But,  whatever 
the  given  conditions  of  alteration  of  the  pitch  as  affected  by  posture, 
the  fact  remains  that,  as  with  Gerhardt's  change  of  sound  in  cavities 
of  the  lung,  so  Biermer's  change  indicates  the  presence  in  the  pleura! 
sac  of  both  air  and  freelv  movable  fluid. 


E.  Cracked-pot  Sound   (Bruit  de  pot  fele) 

The  cracked-pot  percussion  sound  is  frequently  heard  in  connection 
with  amphoric  resonance.  As  its  name  implies,  this  sound  resembles 
that  produced  by  percussing  a  cracked  jar  or  metal  vessel,  and  may 
be  imitated  by  loosely  clasping  the  hands  at  right  angles  to  each 
other,  and  then  sharply  striking  them  (the  back  of  one)  across  the 
knee.  The  concussion  produces  a  sound  which  closely  resembles  the 
chinking  of  coin  held  in  the  hollow  of  the  hands — a  rattling,  some- 
times peculiar  hissing,  metallic  clinking,  tympanitic  sound.  The 
cracked-pot  characteristic  may  also  be  imitated  by  percussing  a  plex- 
imeter  so  lightly  applied  to  the  skin  that  beneath  it  is  left  a  small 
space  containing  air.  In  both  experiments  the  sound  is  caused  by 
the  sudden  discharge  of  air  from  between  the  palms,  or  the  skin  and 
pleximeter,  as  the  case  may  be. 

This  is  virtually  what  happens  when  the  cracked-pot  sound  is 
elicited  over  the  chest  by  a  forcible  percussion  stroke:  it  means  usually 
that  the  air  in  a  pulmonary  cavity  communicating  with  a  bronchus  is 
sharply  expelled  through  the  narrow,  slitlike  opening  at  the  glottis. 

An  abundance  of  crisp  hair  on  the  chest  anteriorly  may  so  inter- 
fere with  the  snug  application  of  a  pleximeter  that  an  air-space,  as 
just  previously  pointed  out,  may  cause  the  cracked-pot  sound  to  be 
simulated  when  the  pleximeter  is  struck  unless  the  hair  is  well  mois- 
tened first,  so  that  it  will  lie  close  and  flat  on  the  surface.  The  sound 
may  occur  normally,  also,  when  percussing  the  chest  of  a  screaming 
child,  though  not  always  necessarily  so,  on  account  of  the  very  thin, 
yielding  thoracic  walls  of  infants.  Very  rarely  is  it  heard  in  healthy 
adults. 


128  PHYSICAL   DIAGNOSIS 

Pathologically,  it  is  produced  : 

(a)  Over  large  lung  cavitiex,  superficially  situated,  especially  at 
the  apex,  when  they  communicate  directly  with  a  bronchus  by  means 
of  a  small  opening,  and  the  overlying  chest  emaciated  to  thinness 
and  elasticity.  The  patient's  mouth  should  be  open,  and  percussion 
made  during  expiration,  so  that  the  sudden  expulsion  of  the  cavity 
air  through  the  opening  may  have  a  free  egress  to  the  outer  air,  other- 
wise the  hissing,  clinking  sound  distinctive  of  cavity  may  not  re- 
spond. It  is  almost  invariably  well  heard  in  the  infraclavicular 
regions.  It  disappears  at  times  during  the  course  of  a  case  that  is 
repeatedly  examined,  owing  to  closure  of  the  bronchial  opening  and 
the  filling  of  the  cavern  with  exudate,  to  return  again  after  the  sub- 
stance has  been  expectorated  by  a  spell  of  coughing.  Another  con- 
dition for  the  production  of  the  cracked-pot  sound,  which  indeed  is 
indicated  by  the  occurrence  of  the  latter,  is  the  thin,  yielding  wall 
of  the  cavity  itself,  whether  composed  of  merely  slightly  thickened 
pleura  on  its  parietal  aspect  or  of  consolidation  of  surrounding  lung. 

The  percussing  finger  should  pause  a  moment  after  striking,  for 
if  lifted  too  soon  the  tympanitic  sound  significant  of  cavity  may  not 
be  elicited,  as  it  is  apt  to  be  subdued  at  the  first  instant  by  the  hiss 
of  the  immediate  rush  of  air  from  the  cavity  into  the  bronchus. 

The  presence  of  a  moderate  amount  of  liquid  in  the  vomica  may  be 
inferred  by  a  commingled  rattling  and  trembling  sound — the  moist 
cracked-pot  sound. 

(6)  In  certain  cases  of  pneumothorax,  usually  circumscribed,  with 
patulous  pleural  opening  in  direct  communication  with  a  bronchus. 
In  this  condition  the  cracked-pot  sound  is  found  over  the  lower  half 
of  one  side  of  the  chest,  in  contradistinction  to  that  of  pulmonary 
cavities,  where  it  is  discovered  over  a  smaller  area  in  the  upper  half, 
and  more  often  anteriorly  than  laterally  or  posteriorly. 

(c)  Similarly,  in  thoracic  fistula,  as  when  an  opening  has  been 
made  into  the  pleural  sac  for  the  evacuation  of  pus  of  an  empyema, 
or  when  air  has-  entered  into  the  pleural  cavity  through  stab  or  gun- 
shot wounds,  whereby  percussion  in  the  immediate  neighborhood  of 
the  orifice  elicits  the  cracked-pot  note,  which  is  also  absent  when  the 
orifice  is  artificially  closed. 

(d)  Over  pneumonitic  lung.    This  occurs  more  commonly  during 
the  congestive  stage,  or  while  there  is  but  partial  consolidation,  in 
which  condition,  it  will  be  remembered,  the  accompanying  immediate 
relaxation  of  lung  causes  a  tympanitic  percussion  sound.     However, 
the  phenomenon  may  be  elicited  not  rarely  even  over  the  hepatized 


PERCUSSION  129 

portion  of  lung  (especially  over  the  upper  lobes  anteriorly),  where 
its  production  must  necessarily  be  due  to  the  sudden  expulsion  of  air 
from  a  large  bronchus  leading  to  the  part  affected.  In  some  cases 
both  causes  may  exist  simultaneously  to  produce  the  bruit  de  pot  fele. 

(e]  Finally,  retraction  or  compression  of  the  lung  above  a  pleuritic 
effusion  favors  the  development  of  cracked-pot  sound  by  affording  the 
condition  of  a  sharp  rush  of  air  from  the  bronchi  with  strong  per- 
cussion strokes. 

In  view  of  the  variety  of  pathologic  conditions,  though  small, 
which  may  operate  to  give  rise  to  cracked-pot  sound,  the  warning  is 
obvious — to  avoid  attributing  its  presence  to  any  one  of  them.  Never- 
theless, its  detection  in  any  patient  evidently  phthisical  is  rather 
clearly  presumptive  of  pulmonary  cavity,  the  other  causes  occurring 
much  less  frequently  and  characteristically. 

Sternal  Percussion. — An  increased  resonance  over  the  sternum 
may  indicate  the  presence  of  a  cavity  in  the  adjacent  lung.  When  the 
resonance  over  the  sternum  persists  as  the  patient  reclines,  but  van- 
ishes when  he  lies  on  one  side,  this  can  be  suggestive  of  hydrothorax 
or  pyopneumothorax.  Banti  was  the  first  to  call  attention  to  the 
retrosternal  dulness  observed  in  case  of  pleurisy  with  effusion,  which 
aids  in  differentiating  it  from  pneumonia. 

F.  The  Lung  Reflex 

This  term  has  been  applied  by  Abrams  to  the  temporary  localized 
emphysema  or  expansion  of  lung,  in  response  to  an  irritant  applied 
to  the  skin  of  the  chest,  such  as  mustard,  so  that  the  percussion  sound 
becomes  for  a  little  while  clearer  in  that  area.  But  the  effect  of 
prolonged  percussion  in  itself  is  similar,  the  continued  repetition  of 
strong  percussion  strokes  giving  rise  to  a  development  of  increased 
resonance  and  volume  of  sound  in  many  cases.  Therefore,  one  must 
not  be  surprised  or  perplexed  to  find  in  prolonged  examinations  or 
demonstrations  of  small  areas  of  dulness,  as  in  tuberculosis,  that  the 
later  percussion  blows  may  elicit  more  and  more  of  the  surrounding 
resonant  quality,  due  to  this  reflex  localized  expansion  of  the  air 
vesicles,  and  correspondingly  less  dulness  or  muffling. 

To  summarize: 

(1)  Vesicular  resonance  is  obtained  over  normal  lung  tissue. 

(2)  Tympanitic  resonance  is  heard  normally  over  the  lower  por- 
tion of  the  left  side  anteriorly,  in  Traube's  semilunar  space  (lung  and 
stomach).     Elsewhere  on  the  chest,  tympanitic  sound  is  pathologic. 

11 


130  PHYSICAL    DIAGNOSIS 

(3)  Impaired  resonance   or    dulness  is  normal  only   over   those 
portions  of  the  heart,  liver,  and  spleen  uncovered  by  lung,  and  over 
the  scapulae  and  very  thick  muscular  and  fat  chest  walls;  its  occur- 
rence over  other  regions  of  the  chest  is  abnormal. 

(4)  Absolute  dulness  or  flatness  may  occur  normally  well  away 
from  the  pulmonary  borders  adjacent  to  the  solid  organs  just  men- 
tioned; pathologically,  it  is  characteristic  of  marked  pulmonary  or 
pleural  infiltration  or  effusion. 

(5)  Cracked-pot  sound,  except  when  obtained  in  percussing  the 
chest  of  a  crying  child,  is  always  an  abnormal  indication. 

(6)  Amphoric  resonance  is  never  normal  over  the  lung  area,  but 
signifies  either  a  large  pulmonary  cavity  or  pneumothorax. 

(7)  Hyperresonance  or  vesiculotympany  is  always  directly  or  in- 
directly a  physical  sign  of  disease. 


ALTERED  CONDITION   OF  LUNG   BOUNDARIES:   POSITION   AND 
MOBILITY  AS   DETERMINED  BY  PERCUSSION 

(a)  Bilateral  extension  of  the  pulmonary  borders  occurs  in  em- 
physema. There  is  simultaneous  loss  of  power  of  displacement  of  the 
borders,  both  with  active  and  passive  mobility.  In  marked  cases 
the  hyperresonance  extends  beyond  all  of  the  normal  lung  boundaries, 
but  especially  the  anterior  and  inferior,  although  the  apices  may 
also  be  higher  than  normal.  Thus,  the  relative,  and  even  the  abso- 
lute, heart  dulness  may  be  entirely  absent,  because  of  the  expanded 
left  lung  completely  covering  the  organ.  The  lower  border  in  the 
midclavicular  line  may  be  found  at  the  seventh  or  eighth  fib,  in  the 
midaxillary  line  at  the  ninth  or  tenth,  and  at  the  eleventh  or  twelfth 
ribs  in  the  scapular  line.  Hepatic  dulness  and  gastric  tympany  are 
correspondingly  diminished  in  area.  The  determination  of  the  de- 
creased or  lost  respiratory  and  postural  mobility  of  the  lung  borders 
may  be  made  in  the  lower  axillae  by  percussing  the  comparatively 
quiescent  lung  just  below  its  edge.  In  the  normal  individual,  at  the 
end  of  a  full  inspiration,  or  while  lying  on  the  left  side,  for  example, 
the  expanding  beneath  causes  the  sound  to  change  suddenly  from 
dull  to  resonant.  In  emphysema,  on  the  contrary,  this  transition  is 
not  perceived,  the  inferior  edge  of  the  lung  being  nearly  or  completely 
motionless  during  inspiration,  the  vesicles  having  lost  their  elasticity, 
and  consequent  capability  of  expansion  and  retraction. 

(6)  Bilateral  diminution  of  extent  of  lung  boundaries,  and  there- 
fore of  the  extent  of  the  vesicular  resonance,  indicates  diminished 


PERCUSSION  131 

volume  of  the  lungs.  This  may  be  general,  as  in  those  predisposed 
to  phthisis,  or  as  found  due  to  the  pulmonary  shrinking  or  collapse 
of  actual  and  active  tuberculosis,  or  it  may  be  manifest  chiefly  in  a 
higher  position  of  the  lower  borders,  due  to  a  pushed-up  diaphragm 
from  a  markedly  distended  abdomen  (meteorism,  ascites,  or  tumor). 
When  the  lungs  are  thus  retracted,  their  borders  are  likewise  mo- 
tionless. 

(c)  Unilateral  extension  of  lung  boundary  downward  is  seen  in 
vicarious  or  compensatory  emphysema,  the  lung  doing  extra  work 
to  accommodate  the  diseased  opposite  lung;  hence,  the  mobility  of 
the  borders  is  well  maintained. 

(d)  Unilateral  retraction  of  lung  boundaries  is  observed  in  cases 
of  shrinking,  as  from  old  pleuritic  adhesions.     Here  the  mobility  is 
apt  to  be  entirely  destroyed. 

(e)  Apparent  unilateral  expansion  is  really  accompanied  by  a 
hyperresonant  or  tympanitic  note  instead  of  the  normal  pulmonary 
resonance,  the  lung  being  pushed  up  by  the  air  in  the  pleural  sac 
of  a  pneumothorax.     The  pathologic  clear  sound  extends  downward 
to  the  lowest  limits  of  the  complementary  pleural  sinus,  is  there 
sharply    delimited   by    percussion,   and   exhibits    a   characteristically 
immovable  border. 

(/)  Diminished  mobility  may  exist  alone,  without  any  change  in 
the  average  extent  of  lung  resonance,  as  the  early  sign  of  an  acute 
pleuritis,  the  pain  causing  restricted  movement  before  sufficient  exu- 
dation has  taken  place  to  give  rise  to  percussion  dulness.  Similarly, 
this  physical  sign  may  evidence  the  presence  of  an  old  pleuritis  with 
thin  adhesions. 

(g)  Retraction  of  the  cardiac  border  of  the  lung  to  the  left  and 
upward  may  so  expose  the  heart  as  to  suggest  its  hypertrophy  or  dila- 
tion, on  account  of  the  apparently  enlarged  area  of  dulness.  A  com- 
parison of  other  signs  will  prevent  error. 


CHAPTER    VI 
AUSCULTATION 

Definition. — Auscultation  is  the  act  of  listening  to  the  sounds 
produced  within  the  body  in  health  and  disease.  Comprehensively, 
it  embraces  the  physiologic  and  pathologic  sounds  of  the  lungs,  heart, 
and  gastro-intestinal  tract;  here  it  refers  to  those  produced  in  the 
act  of  breathing,  and,  of  lesser  importance,  to  those  set  up  by  voice 
vibrations  transmitted  to  the  lungs  and  chest  wall. 

Although  we  may  listen  and  take  note  of  the  sounds  of  coughing, 
wheezy  asthmatic  breathing,  or  thoracic  splashing  sounds  at  a  certain 
distance  from  the  patient,  auscultation  proper  means  the  direct  or 
mediate  application  of  the  ear  to  the  surface  of  the  chest  for  the 
purpose  of  ascertaining  the  significance  of  the  various  sounds  pro- 
duced within.  Hence,  as  suggestively  described  by  A.  L.  Loomis, 
auscultation  is  "  a  kind  of  eavesdropping  " — listening  with  bent  head 
and  applied  ear  while  all  the  time  the  conditions  are  unseen. 

Historical  Note. — That  Hippocrates  should  have  observed  and  de- 
scribed some  of  the  phenomena  of  auscultation  is  not  to  be  wondered 
at  so  much  as  that,  for  centuries  afterward,  so  few,  scattered,  and 
obscure  references  to  auscultation  should  have  been  made.  Thus,  he 
described  and  named  the  succussion  or  splashing  sound  heard  in 
pyopneumothorax,  and,  from  certain  passages  in  his  works,  was  un- 
doubtedly acquainted  with  the  creaking  friction  sound  of  pleuritis 
and  the  rattling  sounds  of  catarrhal  (bronchial?)  affections,  although 
evidently  not  impressed  with  their  real  significance. 

It  was  not  until  after  percussion  had  been  utilized  in  a  limited 
way  for  fifty  years  that  Laennec  (1781-1826),  the  inventor  of  the 
stethoscope,  first  practised  auscultation.  This  was  in  1816.  Three 
years  of  diligent  application  and  observation  enabled  him  to  become 
so  proficient  in  the  method  that  he  had  established  the  diagnostic 
value  of  most  of  the  auscultatory  signs,  and  forthwith  wrote  his 
classic  work,  in  1819,  the  "  Traite  de  1' Auscultation  mediate  et  des 
Maladies  des  Poumons  et  du  Cceur."  Skoda's  critical  analysis  of 
132 


AUSCULTATION  133 

Laennec's  results,  and  his  own  contributions  of  additional  data,  espe- 
cially in  demonstrating  the  physical  causes  for  each  of  the  ausculta- 
tory  signs  discovered,  has  given  us  an  exactitude  of  information  and 
a  simplicity  and  practicality  of  classification  regarding  these  phe- 
nomena that  has  hardly  been  improved  upon  since. 

In  later  years,  much  development  of  skill  in  this  method,  and  of 
precision  in  the  inferences  derived  from  the  physical  signs  elicited, 
as  a  result  of  able  and  frequent  and  painstaking  clinical  and  path- 
ologic investigation,  gives  auscultation  the  most  prominent,  produc- 
tive, and  promising  position  as  a  single  method  of  physical  examina- 
tion among  the  others  in  the  majority  of  cases.  It  has  the  advantage 
that  percussion  lacks,  namely,  comparative  easiness  of  technic.  Acuity 
and  reliability  of  hearing  and  concentration  of  attention  are  as  neces- 
sary in  auscultation  as  in  percussion,  often  even  more  so,  because 
of  the  mingling  of  the  respiratory  and  cardiac  sounds;  nevertheless, 
perseverance  usually  begets  a  grasp  and  mastery  of  both  methods  often 
so  soon  and  suddenly  as  to  be  surprising. 


METHODS 

Auscultation,  like  percussion,  may  be  conducted  in  two  ways: 
immediately  or  mediately.  In  the  former,  the  ear  is  applied  directly 
to  the  chest  wall,  with  nothing  but  a  napkin,  thin,  soft  (unstarched), 
towel,  or  handkerchief  intervening;  in  the  latter,  or  indirectly,  help 
is  derived  by  the  use  of  an  interposed,  tubular,  conducting  instrument 
—the  stethoscope. 

Both  methods  are  used,  and  are  useful,  but  ordinarily  the  imme- 
diate method  is,  perhaps,  more  serviceable,  which  is  quite  the  opposite 
in  examining  the  heart,  where  a  stethoscope  is  essential  in  determin- 
ing the  various  valve  sounds  and  murmurs.  In  general,  it  may  be 
said  that  immediate  auscultation  gives  us  a  better  idea  of  the  con- 
dition of  a  relatively  large  area  of  the  lung,  and  sometimes  of  deep- 
seated  consolidations  and  cavities,  than  does  mediate  auscultation. 
On  the  other  hand,  for  circumscribed,  detailed  work  and  the  more 
superficial  pathologic  areas,  the  aid  of  a  stethoscope  should  be  re- 
sorted to. 

The  subjoined  advantages  and  disadvantages  of  the  two  methods 
may  be  enumerated,  to  serve  as  a  guide  in  judgment  as  to  which  one, 
or  whether  both,  should  be  employed  in  any  particular  case.  The 
principal  advantages  of  immediate  auscultation  are,  that  (a)  it  is  an 


134  PHYSICAL   DIAGNOSIS 

easy  and  ready  method  of  application  to  obtain  a  broad  survey  of  the 
physical  state  of  the  lungs,  and  yet  a  fairly  precise  knowledge  of  not 
too  small  areas,  while  where  rapidity  of  examination  is  required,  as 
in  emergencies  and  in  states  of  exhaustion  or  grave  illness,  in  which 
the  patient  is  unable  to  sit  up  longer  than  a  few  moments,  especially 
to  have  the  back  auscultated,  it  is  almost  indispensable;  (b)  the  purity 
of  the  respiratory  sounds  is  better  preserved;  (c)  slight  and  super- 
ficial as  well  as  deep  changes  of  sound  may  be  appreciated  more 
distinctly  with  the  ear  placed  closely.  In  some  cases  it  has  been  my 
experience  that  certain  rales  and  rustling  pleuritic  friction  sounds, 
pathologic  breath  sounds  even,  as  well  as  certain  cardiac  murmurs 
and  the  aneurismal  bruit,  were  better  recognized  without  than  with 
the  stethoscope;  (d)  palpatory  sensitiveness  of  the  applied  ear  helps 
to  realize  the  character  of  the  chest  movements,  feel  friction  thrills, 
and  discriminate  vocal  vibrations.  The  disadvantages  are  counter- 
balanced by  the  following  dominant 

Advantages  of  Stethoscopic  Auscultation. —  (a)  Accuracy  of  local- 
ization, enabling  one  to  listen  to  sounds  produced  in  a  very  small, 
limited  space;  (&)  intensification  of  the  sounds  from  any  given  cir- 
cumscribed area;  (c)  where  it  is  impracticable,  for  anatomic  reasons, 
to  apply  the  ear,  as  in  the  supraclavicular,  axillary,  and  sometimes 
the  suprascapular  regions;  (d)  whenever,  in  using  the  unaided  cur, 
the  posture  necessary  to  be  assumed  is  constrained,  inconvenient,  or 
awkward;  (e)  sometimes  for  reasons  of  delicacy,  in  examining  fe- 
males, who  may  be  sensitive  in  having  the  head  applied  to  the  breast 
region;  (/)  to  avoid  being  soiled  or  contaminated  by  unclean  clothing 
or  bedding,  and  by  parasites,  or  infected  by  contagious  disease;  (g) 
excludes  external  sounds  (with  the  binaural  stethoscope). 

Among  the  disadvantages  in  the  use  of  the  stethoscope  are  these : 
(a)  It  modifies  the  true  quality  of  the  chest  sounds  by  the  adventi- 
tious roaring  and  other  sounds  due  to  the  construction  and  materials 
of  the  instrument;  (&)  it  intensifies  such  interfering  sounds  as  may 
be  caused  by  the  rubbing  of  hair  within  the  chest  piece,  or  of  adja- 
cent garments  during  the  movements  of  respiration;  (c)  it  may  re- 
quire more  time  to  examine  the  lungs  than  may  be  necessary  or  advisa- 
ble; (d)  babes  are  often  too  restless  and  tender  to  pressure,  even 
slight,  and  children  are  frequently  alarmed  and  irreconcilable  at  the 
sight  of  a  stethoscope;  (e)  in  very  thin  and  emaciated  persons,  the 
circumference  of  the  chest  piece  does  not  fit  closely  throughout,  as 
the  surface  is  too  irregular  on  account  of  the  narrow  elevations  and 
depressions  of  the  ribs  and  intercostal  spaces,  thus  admitting  extrane- 


AUSCULTATION 


135 


ous  sounds;    (/)    a  trifling  and  yet  practical  objection  is  that  the 
stethoscope  is  not  always  conveniently  at  hand. 

The  truth  is  that  both  methods  should  be  learned,  so  that  either 
may  be  adapted  according  to  the  circumstances  and  indications,  atten- 
tion being  given  first  to  the  direct  or  immediate  method  of  ausculta- 
tion, and  then  to  the  mediate  for  special  cases  requiring  detailed 
examination,  as  for  tuberculosis,  where  the  Bowles  stethoscope  is 
almost  essential. 

The  Stethoscope  and  its  Selection. — Stethoscopes  are  of  two  types 
and  classes  of  adaptability  and  construction,  the  single  or  monaural 
and  double  or  binaural,  the  solid  or  stiff,  and  the  flexible.  The 
stethoscope  invented  by  Laennec  consisted  of  one  piece — a  crude 
cylinder  of  wood.  The  simple  stethoscopes  are  now  made  hollow,  of 
hard  rubber  throughout,  or  of  bell-metal  tube  and  chest  piece,  or  of 
bell-metal  tube  and  hard-rubber  chest  and  ear  pieces,  or  of  wood 
only.  The  tube  is  about  4|  to  6  in.  long.  The  conical  or  bell-shaped 
thoracic  end  of  the  monaural  stethoscope  is  preferably  made  of  hard 
rubber,  and  but  f  in.  in  diameter,  and  should  not  exceed  1^  in.  The 
hard-rubber  ear  piece  should  be  large  enough  to  cover  the  whole 
concha,  and  slightly  concave — one  that  is  2$  to  2|  in.  in  diameter 
is  about  right — and  is  usually  detachable  from 
the  tube  by  a  screw  thread,  for  convenience  of 
carrying  in  the  pocket,  as  in  the  Hawksley,  of 
London,  stethoscope.  The  importance  of  a 
well-fitting  ear  plate  has  been  emphasized  by 
Walshe  to  be  "  as  necessary  ...  as  to  try  on  a 
new  hat." 

While  the  SINGLE  STETHOSCOPE  has  been 
used  by  many  able  clinicians  and  practitioners 
with  satisfactory  results  in  the  localization  and 
determination  of  the  character  of  sounds ;  while 
it  is  handy  and,  for  one  whose  hearing  in  one 
ear  is  deficient  or  lost,  is  quite  sufficient,  there 
are  certain  disadvantages,  however,  that  should 
be  pointed  out  here.  In  the  first  place,  it  does 
not  shut  out  the  external  sounds  free  to  enter 
the  other  ear;  and,  when  the  latter  is  held 
closed  by  a  finger,  roaring  sounds  are  apt  to 
be  caused  that  may  be  equally  confusing.  Secondly,  a  common  ob- 
jection is  pressure  with  the  head,  the  weight  of  which  is  not  as  appre- 
ciable by  the  examiner  as  by  the  skin  of  the  patient,  to  whom  the 


T 


FIG.  29.  —  HAWKSLEY'S 
SINGLE  STETHOSCOPE 
(two  pieces).  (Mus- 
ser.) 


136 


PHYSICAL    DIAGNOSIS 


almost  invariable  pressure  marks  represent  unpleasant,  if  not  pain- 
ful, sensations.  This  discomfort  I  have  seen  augmented  by  the  awk- 
wardness which  seems  unavoidable,  especially  by  beginners,  of  having 
the  chest  piece  slip  or  tilt  a  little,  thus  digging  more  deeply  into  the 
skin  on  a  part  of  its  circumference,  all  because  the  auscultator  must 
needs  look  away  from  the  region  of  application  of  the  stethoscope, 
and  because  his  head  is  comparatively  insensitive  to  the  degree  of 
pressure  exerted  or  the  accuracy  of  placing  of  the  bell  end. 

The  BINAURAL  STETHOSCOPE,  for  reasons  soon  to  be  given,  is  now 
much  more  generally  used  than  the  single  one,  although  relatively  more 

often  in  auscultating  the  heart.  A  large  va- 
riety of  double  stethoscopes  has  been  devised 
since  Dr.  Cammann,  of  New  York,  in  1840, 
invented  the  first  one,  composed  partly  of 
metal  and  partly  of  flexible  tubing,  with 
hard-rubber  or  bone  or  ivory  conical  or  crul- 
ler-shaped ear  pieces  attached  to  the  metal 
tubes,  and  a  bell-shaped  hard-rubber  chest 
piece  to  join  the  flexible  ends.  The  auricular 
ends  are  usually  held  to  the  meatuses  by  a 
rubber  band  around  the  far  ends  of  the  metal 
tubes,  or,  more  preferably,  by  either  a  curved 
flat  steel,  or  coiled  wire  spring.  A  rubber 
band,  naturally  or  because  of  accidental 
wettings,  is  more  perishable  as  regard  both 
its  elasticity  and  continuity;  it  also  fre- 
quently causes  painful  pressure  in  the  ears 
when  stretched  to  or  near  its  utmost.  This 
leads  to  the  caution,  that  in  choosing  an  in- 
strument one  should  never  be  selected  un- 
less its  adjustment  to  the  ears  is  absolutely 
comfortable  both  as  to  shape  of  the  ear 
cones  and  strength  of  spring.  On  the  other 
hand,  as  in  those  with  narrow  heads,  spe- 
cial care  must  be  exercised  to  avoid  a  spring 
so  weak  and  loose  that  the  proper  conduction 
of  thoracic  sounds  to  the  ears  is  not  an- 
nulled or  interfered  with. 
The  car  pieces  should  curve  so  as  to  point  in  the  direction  of  the 
ear  canal — that  is,  downward  and  forward.  Spheroidal  ear  pieces  are 
less  likely  to  press  too  deeply  and  uncomfortably  into  the  ear  canal 


FIG.  30. — CAMM ANN'S  DOU- 
BLE STETHOSCOPE  AND 
SNELLJNQ'S  RUBBER  BELL. 

(Musser.) 


AUSCULTATION  137 

t 

than  conical  ones.  The  tubes  need  not  be  larger  in  caliber  than  the 
entrance  of  the  auditory  canal.  The  rubber  tubing  which  joins  the 
metallic  tubes  to  the  thoracic  piece  should  be  as  soft  and  flexible  as 
is  consistent  with  purity  and  dura- 
bility of  material,  and  should  be  of 
sufficient  length  so  as  to  allow  the 
examiner  to  change  the  position  of 


FIG.  31. — SIMPLE  FORM  OF  SANSOM'S  BIN- 
AURAL  STETHOSCOPE.      (Tyson.) 


FIG.  32. — BINAURAL  STETHOSCOPE. 

(Musser.) 


the  chest  piece  frequently  without  having  to  move  his  head  or  body 
each  time,  as  must  be  done  with  the, stiff  woven  tubing,  and  so  that 
the  stethoscope  may  be  conveniently  folded  for  the  pocket. 

Jointed  stethoscopes,  however,  whether  of  the  hinged  spring  vari- 
ety that  fold  longitudinally  or  vertically  by  the  metallic  tubing  near 
the  spring,  or  that  are  detachable  where  the  metallic  and  metallic- 
tipped  rubber  or  woven  tubings  meet,  should  be  avoided.  They  annoy, 
and  pervert  and  confuse  the  characteristic  sounds  of  the  chest  by  occa- 
sional squeaks  and  metallic  creaks,  intensified  by  the  conductivity  of 
the  instrument;  the  smooth  metallic  junctures  may  also  slip  apart  with 
a  harsh  shock  to  the  ears  and  a  disagreeable  break  in  the  auscultation. 


138 


PHYSICAL    DIAGNOSIS 


The  chest  piece  is  made  of  hard  rubber  or  wood,  and  in  order 
that  it  may  easily  be  placed  in  the  intercostal  spaces,  should  not  exceed 


FIG.  33. — AUTHOR'S  BINAURAL  STETHOSCOPE  CHEST  PIECE. 

£  in.  in  diameter.  Ordinarily  the  chest  piece  should  not  be  so  thick- 
walled  as  to  make  its  interior  caliber  at  the  upper  half  as  small  as  in 
some  makes  of  instrument,  particularly  if  the  bell  is  more  than  1  in. 
in  length,  but  should  maintain  a  rather  free 
opening  to  where  the  rubber  tubes  join  it,  so 
that  the  partial  partition  between  them  may 
be  seen  within  the  aperture. 

When  a  larger  thoracic  piece  is  desirable, 
and  one  that  will  lie  in  close  to  the  skin  re- 
gardless of  elevations  and  depressions,  a  soft 
rubber  bell  may  be  attached,  as  in  the  very 
satisfactory  Valentine  stethoscope,  which 
conducts  and  augments  the  sounds  re- 
markably well.  The  efficiency  of  this 
instrument  depends  partly  upon  the  sim- 
plicity of  construction  and  uniformity  of 
material  (mostly  of  hard  rubber),  and  part- 
ly on  account  of  the  smooth  finish  of  the  in- 
terior of  the  tubing  and  the  absence  of 
unnecessary  curves  in  the  tubes  connected 
with  the  ear  pieces. 

The  BOWLES  STETHOSCOPE  deserves  spe- 
cial notice  as  the  most  recent  and  adaptable 
sound  intensifier  in  use.  As  shown  by  the 
illustration,  it  differs  essentially  from  other 
binaural  stethoscopes  in  the  chest  piece. 
This  is  somewhat  like  a  telephone  receiver,  consisting  of  a  shallow 
cup  of  steel,  over  the  mouth  of  which  is  fitted  a  diaphragm  of  hard 


FIG.  34. — BOWLES'  STETHO- 
SCOPE.    (Tyson.) 


AUSCULTATION  139 

rubber,  thin  metal,  or  animal  membrane,  about  2  in.1  in  diameter, 
held  in  place  by  a  steel  ring.  The  disk  prevents  the  projection  of 
the  chest  tissues  into  the  cup,  and  may  also  serve  partly  as  a  reso- 
nator, although  this  is  denied  by  some  clinicians.  For  bedside  in- 
struction, the  Bowles  stethoscope  may  have  2,  4,  6,  or  even  12  pairs 
of  ear  pieces  joined  to  it,  so  that  as  many  students  may  listen  simul- 
taneously with  the  demonstrator,  and  thus  save  the  time  of  the  exam- 
iners and  the  strength  and  patience  of  the  patient.  The  transmission 
of  thoracic  sounds  through  so  much  tubing  of  the  multiple  Bowles 
stethoscope  diminishes  their  distinctness  as  compared  with  their  loud- 
ness  when  heard  with  the  single  instrument,  but  is  about  as  effective 
as  with  the  ordinary  double  stethoscope. 

The  advantages  of  the  binaural  stethoscope  over  the  monaural 
are,  briefly,  greater  clearness  and  intensification  of  sounds,  directly 
because  of  the  nature  of  the  instrument,  indirectly  because  with  it 
external  sounds  are  excluded  more  easily.  Again,  one  sees  precisely 
where  the  chest  piece  is  placed  while  listening,  that  it  does  not  slip, 
and  feels  sensitively  with  the  holding  finger  and  thumb  that  it  does 
not  press  uncomfortably  or  unevenly,  or  rub  against  hair  or  clothing. 
And  then,  for  those  whose  hearing  is  defective,  the  double,  the  Bowles 
stethoscope  especially  is  very  helpful.  Also,  with  the  latter  one  may 
quite  often  hear  distinctly  the  pulmonary  and  cardiac  sounds  through 
several  not  too  thick  garments, .  as  where  rapid  or  emergency  work 
may  be  required.  And  again,  with  the  Bowles,  the  larger  chest  piece 
enables  the  examiner  to  auscultate  almost  as  large  a  lung  area  as 
with  the  unaided  ear.  Finally,  this  same  variety  of  stethoscope  is  an 
admirable  safeguard  and  convenience  in  examining  the  posterior  re- 
gions of  the  lungs  in  patients  who  may  be  too  ill  or  exhausted,  as  from 
pneumonitis,  to  be  moved  to  a  sitting  or  even  a  side  posture;  for,  by 
simply  pressing  down  the  bedclothes,  the  flat  chest  piece  may  easily 
be  applied  to  the  back  and  axilla?. 

A  binaural  stethoscope  may  have  these  disadvantages,  namely:  to 
learners  in  particular,  until  accustomed  to  its  use,  the  accompanying 
humming  sound,  especially  if  slight.,  tends  to  confuse  or  subordinate 
the  true  respiratory  sounds,  unless  loudly  manifest ;  but  the  rhythmic 
character  of  the  functional  sounds  are  soon  readily  differentiated  from 
the  instrumental  hum.  The  larger  size  of  the  Bowles  chest  piece 
prevents  its  being  used  satisfactorily  in  the  supraclavicular  spaces, 
and  between  the  ribs  in  emaciated  subjects. 

1  There  is  also  a  useful  1 J  in.  disk. 


140 


The  PHONENDOSCOPE,  devised  by  the  Italians  Bazzi  and  Bianchi, 
though  similar  in  the  construction  of  its  thoracic  end,  has  no  advan- 
tage over  the  ordinary  stethoscope  for  general  auscultation,  and,  on 
the  other  hand,  is  less  convenient  to  carry 
and  use.  It  consists  of  a  metallic  drum  sim- 
ilar to  but  deeper  than  that  of  the  Bowles 
stethoscope,  and  a  little  larger  in  diameter, 
to  the  under  side  of  which  two  hard-rubber 
disks  are  attached,  an  inner  for  direct  appli- 
cation to  the  chest,  and  an  outer,  which  may 
be  screwed  down  almost  in  contact  with  the 
other  by  means  of  a  retaining  metallic, 
millgd-edged  rim.  In  the  center  of  the  outer 
disk  is  an  opening,  into  which  may  be  screwed 
a  steel  stem  about  2  in.  long  and  $  in.  in 
diameter,  at  the  outer  extremity  of  which  a 
hard-rubber  button  is  fixed,  about  £  in.  in 
diameter.  The  inner  disk  is  applied  when 
large  areas  are  to  be  examined,  more  partic- 
ularly of  the  lungs,  while  the  outer  disk  and 
buttoned  stem  are  used  when  very  small 
areas,  especially  the  valves  of  the  heart,  are 
to  be  auscultated,  or  in  the  practise  of  aus- 
cultatory  percussion.  When  not  in  use  the 
stem  is  held  by  two  small  rings  on  the  top 
of  the  drum,  where  also  the  soft-rubber  con- 
ducting tubes,  with  their  ear  pieces,  are  at- 
tached. The  phonendoscope  is  indeed  a  sen- 
sitive instrument,  slight  alterations  in  the 
breath  sounds,  mucous  clicks,  friction  rus- 
tles, and  murmurs  being  intensified  to  a  more  distinct  audibility,  and 
the  changes  of  tone  and  pitch  in  approaching  the  borders  of  organs 
being  mapped  out  by  auscultatory  percussion,  or  merely  scratching  the 
skin  near  the  stem  button  as  it  is  moved  accordingly,  are  especially 
helpful  in  accurate  physical  diagnosis. 

The  DIFFERENTIAL  STETHOSCOPE,  which  is  practically  a  divided 
binaural  instrument,  with  two  separate  soft,  flexible  tubes  attached 
respectively  to  a  chest  piece  for  each  ear  to  receive  sounds  through, 
may  serve  a  valuable  amount  of  information  in  comparative  work. 
Thus,  it  may  be  used  to  determine  differences  in  time  or  rhythm  of 
abnormal  respiratory  sounds  over  different  localities  simultaneously, 


Fia.  35. — PHONENDOSCOPE 
A,  metallic  rod. 


AUSCULTATION  141 

or  in  the  quality  or  loudness,  synchronousness,  or  transmissibility  of 
cardiac  murmurs. 

After  all  that  has  been  said,  the  student  should  choose  that  stetho- 
scope which  best  evidences  good  augmenting  and  transmitting  capac- 
ity, simplicity  and  durability  of  make,  comfort,  and  convenience  in 
handling,  and  then  stick  to  that  until  he  is  thoroughly  accustomed 
to  its  individual  peculiarities  in  conveying  auditory  impressions  under 
various  circumstances  and  in  the  varying  conditions. 

Technic  of  Auscultation. — The  patient  should  be  in  a  quiet  room, 
so  that  the  examiner  may  not  be  interrupted  and  handicapped  by 
noises  and  talking.  Both  persons  should  assume  easy,  comfortable, 
and  unconstrained  positions.  If  possible,  the  patient  should  stand 
or  sk,  the  arms  hanging  loosely,  as  foi»  inspection,  a  blanket  being 
thrown  over  the  shoulders  to  avoid  any  chill.  The  attitude  should 
also  be  symmetrical,  any  lateral  or  twisted  posture  of  the  body,  as 
by  supporting  one  hand,  or  resting  on  one  foot,  or  leaning,  causing 
unequal  breathing  movements  on  the  two  sides.  In  examining  the 
posterior  surface  the  patient  bends  the  body  slightly  forward,  folding 
the  arms  in  front  of  the  chest,  as  for  percussion.  In  direct  ausculta- 
tion, the  surface  to  be  auscultated  must  have  nothing  between  it  and 
the  observer's  ear  but  a  thin,  soft  towel,  handkerchief,  or  light-weight 
undershirt,  while  for  stethoscopic  work  the  skin  must  be  bared,  in 
women  as  well  as  men,  although  in  some  cases  determination  and  tact 
of  manner  and  speech  may  be  necessary.  In  those  who  are  so  ill 
that  recumbency  is  imperative,  after  examining  the  anterior  regions 
of  the  chest  with  the  patient  lying  flat,  he  may  be  turned  gently  to 
either  side,  care  being  taken  not  to  exhaust  him  by  too  lengthy  an 
examination,  but  reserving  the  less  essential  regions  for  subsequent 
investigation.  Then  the  back  may  be  auscultated  more  conveniently 
by  having  the  night-dress  open  there  by  a  long  slit  from  the  neck 
down. 

As  it  is  necessary  that  both  sides  of  the  chest  should  be  able  to 
move  with  equal  freedom,  constricting  clothing,  corsets,  braces,  and 
the  like  should  be  released  or  removed;  and  the  fallacious  habit  of 
auscultating  one  side  and  then  the  other,  in  front,  while  the  patient 
alternately  holds  open  and  aside  the  intervening  garments,  must  par- 
ticularly be  avoided,  so  as  to  prevent  the  imperfect  and  uneven  results 
of  muscle-sound  interference  and  altered  respiratory  movement  on 
the  two  sides  due  to  muscular  constraint. 

At  the  commencement  of  auscultation  it  is  usually  advisable  to 
listen  to  the  breathing  sounds  while  the  patient  respires  as  he  is 


142  PHYSICAL    DIAGNOSIS 

ordinarily  accustomed  or  inclined  to  do.  Some  persons  become  nerv- 
ou>]v  confused  and  puzzled  when  requested  to  breathe  naturally; 
others  require  absolute  and  explicit  guidance  and  directions,  and  coor- 
dinate their  respiratory  variations  of  movement  quite  satisfactorily. 
In  all  cases,  a  natural  ease  and  freedom  of  expansion,  with  the  mouth 
closed,  should  be  aimed  for.  The  respirations  should  be  deep,  gradual, 
and  regular,  and  not  violent,  sharp  or  sudden,  and  jerky  or  rapid. 
Grunting,  moaning,  and  moist  clicking  or  rattling  sounds  in  the 
throat  should,  as  much  as  possible  during  auscultation,  be  suspended 
by  instructions  to  the  patient,  or  be  allowed  for  as  to  their  origin. 
We  may  aid  the  patient  by  performing  the  respiratory  act  properly 
ourselves,  and  then  having  him  imitate  us  as  closely  as  possible. 
Asking  the  patient  to  sigh  helps  to  elicit  a  satisfactory  breath  sound ; 
coughing  may  do  likewise,  the  few  inspirations  immediately  following 
being  necessarily  full. 

To  insure  placing  the  ear  exactly  over  the  spot  to  be  auscultated, 
it  is  well  to  put  the  tip  of  the  index  finger  at  the  point  desired,  and 
then  apply  the  ear  so  that  the  auditory  opening  corresponds  to  the 
place. 

The  examination  should  be  conducted  systematically  and  compara- 
tively :  we  first  auscultate  the  apices,  then  the  lower  regions  anteriorly, 
then  the  lateral  and  posterior  aspects  of  the  chest,  always  comparing 
corresponding  parts  of  the  chest  on  the  two  sides.  Often  it  is  neces- 
sary to  contrast  different  regions  on  the  same  side.  No  auscultation 
is  complete  unless  the  entire  chest  is  examined  carefully  and  critically, 
as  evidences  of  disease  may  be  discovered  where  such  symptoms  as 
pain  may  be  absent.  It  is  better  not  to  linger  too  long  over  one  spot, 
so  as  to  avoid  confusion  of  the  ear  by  too  marked  an  auditory  im- 
pression, but  rather  to  frequently  alternate  between  symmetrical  re- 
gions so  as  to  note  slight  differences  of  sound  that  may  have  any 
pathologic  significance.  It  is  well  also  to  get  accustomed  to  using 
both  ears,  should  any  exigencies  in  regard  to  the  disability  of  an 
inconveniently  postured  patient  or  on  the  part  of  one  of  the  exam- 
iner's ears  arise. 

The  Use  of  the  Stethoscope. — Next  to  the  selection  of  a  suitable 
stethoscope  is  its  proper  application  in  practise.  With  the  binaural 
the  student  can  readily  become  accustomed  to  its  intrinsic  character- 
istics, and  the  normal  breath  as  well  as  heart  sounds,  by  applying 
the  chest  end  to  his  own  bared  skin  before  using  it  upon  that  of  his 
fellows  and  obliging  friends,  and  then  upon  hospital  attendants,  con- 
valescents, and  patients. 


AUSCULTATION  143 

The  essential  thing  about  the  act  is  really  mental  rather  than 
mechanical ;  that  is,  concentration  of  attention  must  be  trained  so  that 
one  learns  to  hear  only  those  functional  sounds  to  which  the  perception 
may  be  directed.  In  listening  to  the  breath  sounds,  for  example,  the 
heart  sounds  are  also  heard  with  more  or  less  distinctness,  according 
to  the  location  auscultated;  but  while  the  ear  naturally  receives  the 
vibrations,  the  mind  must  hear  the  respiratory  murmur  alone,  and 
deliberately  disregard  all  other  sounds  for  the  moment,  whether  or- 
ganic or  external  to  the  body.  To  hear  the  breath  sounds  merely  is 
not  difficult  ordinarily,  but  to  discriminate  them  from  the  extraneous 
and  cardiac  sounds,  as  one  wills,  requires  training  to  attain,  just  as 
one  may  attend  to  the  words  spoken  by  another  in  conversation,  or 
to  the  ticking  of  a  clock,  although  the  sound  vibrations  of  both  are 
being  transmitted  to  the  auditory  apparatus. 

The  points  of  disadvantage  of  the  single  and  binaural  stethoscopes 
already  enumerated  may  indicate  some  of  the  errors  to  be  avoided  in 
their  use.  Thus,  care  must  be  exercised  that  painful  pressure  is  not 
produced  by  the  head  in  using  the  monaural  instrument,  and  that  it 
does  not  tilt  or  slip,  and  so  cause  part  of  the  chest-piece  circumference 
to  be  without  contact,  or  to  prematurely  change  its  location. 

With  the  double  stethoscope  one  sees  the  position  of  the  chest 
end,  and  with  the  thumb  and  finger  may  press  with  just  sufficient 
firmness  to  secure  perfect,  comfortable,  and  stable  apposition,  at  the 
same  time  resting  the  little  finger  on  the  chest,  if  necessary.  Patients 
who  are  standing  or  sitting  while  under  examination,  and  who  may 
be  easily  inclined  to  shrink  away  under  the  pressure  of  a  stethoscope, 
should  be  supported  by  the  examiner's  free  hand  placed  around  the 
back,  for  instance,  when  auscultating  the  front  of  the  chest. 

Not  only  must  one  learn  to  disregard  unavoidable  noises  from  the 
street  or  building,  or  even  in  the  room  where  the  auscultation  is  done 
— although  in  the  latter  quiet  should  be  insisted  on — but  also  those 
extraneous  sounds  produced  by  the  manipulations  of  the  stethoscope, 
and  especially  the  rubbing  sounds  occasionally  caused  by  hair  on  the 
chest,  or  by  an  adjacent  garment.  Unless  carefully  recognized  by 
moving  the  chest  piece  over  the  skin  and  noting  the  results,  pleural 
or  pericardial  friction  sounds  may  wrongly  be  inferred.  A  harsh, 
very  dry,  and  hairy  skin  may  be  oiled  so  as  to  prevent  any  crepitating 
sounds  of  a  deceptive  character,  or  a  soft-rubber  cap  may  be  put  over 
the  chest  piece. 

Clicking,  snapping,  or  crackling  sounds,  due  to  slight  motion  of 
metallic  hinged  or  adjusted  parts,  the  vibrations  of  a  spring,  or  the 


144  PHYSICAL    DIAGNOSIS 

movements  of  the  fingers  holding  the  chest  piece,  may  resemble  ab- 
normal adventitious  sounds  from  within  the  thorax  unless  accounted 
for  by  close  observation.  Movements  of  the  examiner's  head  while 
auscultating  may  result  likewise.  To  avoid  finger-friction  sounds  the 
chest  end  should  be  grasped  so  firmly  that  there  may  be  no  slipping. 
Kinking  of  the  rubber-tube  connections,  or  their  contact  with  the 
skin  or  clothing,  should  be  guarded  against  also. 

It  is  important  that  the  ear  pieces  point  upward,  as  the  metallic 
tubing  is  held  horizontally  before  placing  the  stethoscope  to  the  ears, 
as,  if  they  are  introduced  in  the  downward  pointing  direction,  their 
openings  press  against  the  wall  of  the  ear  canal  instead  of  being 
directed  axially,  and  thus  humming  sounds  interfere  with  those  from 
the  thorax. 

Finally,  the  importance  of  having  the  patient  assume  an  easy, 
relaxed  position  during  stethoscopic  auscultation  is  seen  in  view  of 
the  fact  that  the  sounds  of  muscular  contraction  are  more  readily 
perceived  than  when  the  ear  is  directly  applied  to  the  chest,  and  that 
they  may  be  mistaken  for  rales  of  the  "  distant "  or  "  indeterminate  " 
type,  sometimes  referable  to  obscure  or  subacute  pleural  or  pulmonary 
conditions.  The  tension  of  chest  muscles  is  more  noticeable  during 
inspiration  than  expiration  (over  the  pectorals  in  front  and  the  trape- 
zius  and  latissimus  behind),  especially  in  those  who  endeavor  nerv- 
ously to  maintain  an  erect  and  favorable  position. 

Muscle  sounds  have  a  low-pitched,  continuous  roaring  quality,  or 
consist  of  several  short,  dull,  higher-pitched  rumbles  rapidly  succeed- 
ing each  other.  They  are  analogous  to  the  sounds  produced  by  strong 
contractions  of  the  masseter  muscle  while  the, teeth  are  clenched;  if 
at  the  same  time  the  ears  are  held  closed  with  the  fingers,  one  -hears 
typical  muscle  sounds. 

The  adventitious  sounds  or  rales  associated  with  pulmonary  dis- 
eases may  be  distinguished  from  these  muscle  sounds  by  their  more 
bubbling  or  crackling  character,  their  clearer  and  more  sharply  de- 
fined quality,  and  shorter  duration. 

AUSCULTATORY  PHENOMENA 

Objects. — Auscultation  is  practised  for  the  purpose  of  studying 
principally  three  classes  of  physical  signs:  (1)  The  respiratory  mur- 
murs, or  breath  sounds;  (2)  rales  and  friction  sounds — superadded 
abnormal  sounds;  (3)  vocal  resonance,  or  the  sounds  of  the  voice; 
transmitted  cough  and  heart  sounds  may  be  included  here. 


AUSCULTATION  145 

THE  SOUNDS   OF  NORMAL  RESPIRATION 

In  listening  over  the  normal  chest  we  detect  two  types  of  respira- 
tory murmur:  (a)  the  vesicular ;  (b)  the  bronchial.  A  third  variety 
of  breath  sound  is  heard  normally  which  consists  of  a  combination 
of  these  two  types,  and  is  therefore  called  bronchovesicular  breathing 
— the  "  indeterminate  "  murmur  of  European  writers. 

These  types  of  breath  sounds  are  recognized,  however,  not  by  a 
mere  naming  of  either  as  it  may  be  found  at  a  particular  designated 
spot,  but  by  an  attentive,  painstaking,  critical  examination  and  anal- 
ysis of  the  attributes  or  elements  which  give  them  their  special  char- 
acteristics. This  pertains  to  both  the  inspiratory  and  expiratory 
sounds.  Thus,  we  learn  to  distinguish  each  variety  of  respiratory 
murmur  by  (as  in  percussion)  the  quality,  audibility  or  loudness, 
pitch,  duration,  and  the  relative  length  of  inspiration  to  expiration,  or 
rliy  thm. 

( 1 )  Bronchial  Breathing. — This  type  of  breath  sound  is  described 
first  because  it  is  easy  to  recognize,  and,  although  not  heard  over 
normal  lung  parenchyma,  is  nevertheless  the  most  commonly  met 
with  where  the  vesicular  breathing  is  abolished,  especially  in  pneu- 
monitis  and  tuberculosis.  Normally,  it  is  heard,  however,  if  one 
places  the  stethoscope  against  the  trachea,  just  above  the  suprasternal 
notch,  or  over  the  larynx,  or  over-  either  of  the  primary  bronchi  near 
their  union  with  the  trachea,  at  the  upper  portion  of  the  sternum. 
The  sound  of  bronchial  breathing  is  harsh,  blowing,  tubular  in  qual- 
ity. It  is  loud,  high  in  pitch  both  during  inspiration  and  expiration, 
depending  upon  the  strength  and  rapidity  of  the  breathings,  though 
the  expiratory  sound  is  frequently  higher  pitched  than  the  inspiratory, 
and  each  commences  and  ends  with  a  sustained  intensity  and  pitch. 
Both  sounds  may  be  equal  in  duration,  but  more  often  expiration  is 
heard  a  little  longer  than  inspiration.  There  is  a  slight  break  or 
pause  between  them,  probably  due  to  the  fact  that  the  inspiratory 
sound  does  not  continue  quite  as  long  as  the  inspiratory  act. 

Skoda  very  well  described  the  quality  of  the  sound  of  bronchial 
breathing  as  corresponding  closely  to  that  produced  by  putting  the 
mouth  in  the  position  of  pronouncing  the  German  "  ch  "  or  the  rough 
aspirate  "  h,"  and  then  breathing  deeply  and  regularly.  It  may  be 
imitated  also  by  blowing  through  a  tube,  as  a  single  stethoscope  of 
good  caliber.  The  physical  attributes  of  intensity,  pitch,  and  dura- 
tion of  the  bronchial  breathing  sound  are  characteristic  of  it,  and  have 
no  necessary  relation,  in  their  various  alterations,  to  those  of  the 
12 


146 


PHYSICAL    DIAGNOSIS 


vesicular  type  of  breathing  sound.  That  is,  the  student  may  remem- 
ber that  such  an  acoustic  law,  for  instance,  as  the  lower  the  pitch  the 
louder  the  sound,  ceteris  paribus,  holds  for  either  the  bronchial  or 
the  vesicular  breathing  sounds,  respectively;  but  it  may  not  do  so 
interchangeably  under  either  normal  or  pathological  conditions,  since 
the  qualities  are  entirely  different,  and  these  are  fundamental.  This 
statement  is  made  here  to  anticipate  the  confusion  of  mind  which  I 
have  witnessed  in  many  students  at  the  seeming  contradiction  of  high- 
pitched,  loud  bronchial  breath  sound  and  comparatively  low-pitched 
vesicular  murmur  of  soft  intensity:  these  are  their  respective  charac- 
teristics, regardless  of  any  relation  of  the  variable  attributes  of  one 

to  the  other,  while  such  varia- 
tions (normal  or  pathologic)  of 
either  are,  of  course,  subject  to 
the  laws  of  sound  already  indi- 
cated. 

Bronchial  breathing  is  also 
heard  in  the  interscapular  space, 
near  the  root  of  the  lungs.  It  is 
produced  by  the  impartation  of 
motion  to  the  tracheobronchial 
column  of  air  by  the  eddylike 
currents  set  up  during  inspi- 
ration at  the  rima  glottidis. 
Therefore,  it  is  here,  over  the 
larynx,  that  the  breath  sounds 
have  the  loudest,  harshest  qual- 
ity. Care  should  be  taken  not  to 
be  deceived  by  the  pharyngeal 
sound  sometimes  very  audible 
while  the  person  examined 
breathes  with  the  mouth  closed, 
nor  by  the  lip  murmur  sometimes 
caused,  as  when  the  mouth  is 
open. 

Normal  variations  are  met 
with.  Thus,  the  sound  is  often 
harsher  when  the  mouth  is 

closed.  The  deeper  the  breathing  the  louder  the  sound.  It  is  more 
distinct  over  the  right  than  over  the  left  bronchus,  near  the  tra- 
cheal  junction.  The  superior  boundary  of  its  audibility  is  the 


FIG.  36. — DOTTED  AREA  SHOWS  WHERE 
BRONCHIAL  (LARGER  DOTS)  AND  BRON- 
CHO -  VESICULAR  (SMALLER  DOTS) 
BREATHING  NORMALLY  EXIST.  Note 
higher  origin  of  bronchus  to  right 
upper  lobe  compared  with  that  to 
left  upper  lobe.  Shows  also  line 
of  demarcation  between  upper  and 
lower  lobes  of  left  lung  anteriorly. 
(Butler.) 


AUSCULTATION 


147 


seventh  cervical  vertebra.  In  persons  with  thick,  heavy  chest 
walls,  the  intensity  of  the  bronchial  sound  may  be  decidedly 
diminished,  but  the  tubal,  piping  quality,  and  high-pitched, 
relatively  prolonged  expiration  is  nevertheless  characteristically 
audible. 

(2)  Normal  bronchovesicular  breath  sound  is  an  imperfect  variety 
of  bronchial  breathing,  having  some  of  the  attributes  of  the 
vesicular  or  true  lung 
sound  without  having 
lost  those  of  the  bron- 
chial; it  is  an  inter- 
mediate, indeterminate, 
or  mixed  respiratory 
sound,  on  the  border- 
line between  bronchial 
and  vesicular  respira- 
tion. It  is  heard  espe- 
cially over  the  right 
apex,  including  the 
right  infraclavicular  re- 
gion; also  in  passing 
with  the  stethoscope 
from  the  trachea  and 
one  of  the  primary  bron- 
chi over  the  sternum, 
downward  and  outward 
for  a  very  short  distance, 
variable  in  different  indi- 
viduals, barely  more  than 
1  to  2  in.,  until  the  vesic- 
ular type  of  lung  paren- 
chyma is  reached  unmodified  by  the  predominance  and  largeness  of 
caliber  of  adjacent  bronchial  tubes. 

The  bronchial  element  mixed  with  the  vesicular  which  the  bron- 
chus on  the  right  side  imparts  in  the  infraclavicular  region  is  a  feature 
of  considerable  practical  importance  which,  when  taken  in  connection 
with  the  other  normal  physical  signs  in  this  region,  may  easily  be 
mistaken  for  the  physical  evidences  of  the  early  stage  of  tuberculosis, 
as  compared  with  the  left  side.  The  expiration  is  a  little  harsher, 
higher  in  pitch,  and  longer  than  that  of  the  vesicular  breathing,  but 
a  little  less  pronounced  in  these  characteristics  than  in  the  bronchial 


FIG.  37. — SHOWING  THE  SITE  OF  NORMAL  BRON- 
CHIAL (LARGE  DOTS)  AND  BRONCHO-VESICU- 
LAR (SMALL  DOTS)  RESPIRATION  POSTERIORLY. 
(Butler.) 


148  PHYSICAL    DIAGNOSIS 

breathing.  Inspiration  is  also  slightly  feebler,  relatively  longer,  and 
lower  pitched  than  the  bronchial  sound. 

(3)  Vesicular  Breathing. — This  is  typical  normal  lung  sound, 
heard  wherever  the  larger  bronchi  are  not  within  auscultatory  dis- 
tance; that  is,  it  is  audible  over  every  portion  of  the  chest  wall  cor- 
responding to  the  surface  of  the  lungs,  with  the  average  exception 
of  the  right  infraclavicular  space  inside  the  midclavicular  line  and 
the  interscapular  region  to  the  third  or  fourth  dorsal  vertebra.  It  is 
most  distinctively  heard  in  the  infrascapular  region,  in  good  breathers 
in  the  axillary  regions,  and  in  the  left  infraclavicular  region  not  too 
near  the  left  bronchus.  Its  characteristic  QUALITY  is  breezy,  rustling, 
like  the  sighing  sound  produced  at  a  distance  by  leafy  tree  branches 
in  a  grove  swayed  by  a  gentle  wind,  whereas  the  bronchial  sound  may 
be  likened  more  to  the  piping  swish  of  a  wintry  blast  through  the 
bare  boughs  of  a  forested  plot.  The  vesicular  sound  may  be  imitated 
most  nearly  by  placing  the  lips,  almost  closed,  in  the  position  to  say 
"  f  "  or  "  v,"  and  then  gently  drawing  a  current  of  air  inward,  as  for 
the  "  f,"  to  reproduce  the  inspiratory  portion  of  the  sound,  while  the 
short  expiratory  sound  is  simulated  better  by  the  "  v  "  characteristic 
in  letting  the  breath  escape. 

The  INTENSITY  of  the  vesicular  sound  varies  in  different  indi- 
viduals, being  generally  softer  and  feebler  to  a  marked  degree  as 
compared  to  the  tracheal  or  bronchial  breath  sound,  and  in  some 
instances  hardly  audible  at  all.  The  inspiratory  part  of  the  sound 
is  louder  than  the  expiratory.  It  does  not  commence  in,  but  ascends 
to  its  maximum  intensity,  which  is  not  quite  maintained,  however, 
up  to  the  end  of  the  act,  or  the  beginning  of  expiration ;  on  the  other 
hand,  the  expiratory  sound  is  loudest  at  its  commencement,  and  dies 
away  so  rapidly  that  it  ceases  to  be  heard  throughout  nearly  the  latter 
three-fourths  of  the  expiratory  relaxation  of  the  alveoli  and  recoil 
of  the  chest  wall. 

Compared  with  the  PITCH  of  laryngeal  or  bronchial  breathing, 
that  of  the  vesicular  murmur  is  low.  The  expiratory  sound  is  usually 
lower  in  pitch  than  the  inspiratory,  although  in  some  cases,  as  pointed 
out  by  a  few  authors,  it  may  be  slightly  higher;  I  have  found  this 
to  be  so  principally  in  children. 

The  relative  DURATION  of  inspiration  and  expiration  is  character- 
istic of  the  vesicular  breath  sound;  that  is,  the  former  is  three  or 
four  times  longer  than  the  latter.  Eight  here  a  careful  discrimina- 
tion must  be  made  to  avoid  a  seeming  contradiction  between  the 
physiologist  and  the  physical  diagnostician,  and  consequent  confusion 


AUSCULTATION  149 

in  the  student's  mind.  For,  as  a  physiologic  function  or  act,  the 
ratio  of  inspiration  to  expiration  is  about  as  5  to  6,  in  relative  lengths ; 
whereas,  as  a  clinical  fact,  their  relative  durations  of  audibility  are 
as  3  or  4  to  1.  The  inspiratory  sound  is  heard  with  sufficient  length 
to  indicate  its  breezy  quality,  while  the  expiratory  sound  is  heard,  if 
at  all,  as  a  mere  soft  puff  or  whiff  of  air.  Thus  it  is  that  absence 
of  the  expiratory  murmur  is  practically  never  pathologic,  a  relative 
lengthening,  on  the  other  hand,  accompanying  nearly  all  of  the 
morbid  conditions  of  the  lung. 

An  important  feature  of  normal  vesicular  respiration  is  the  very 
short  pause  between  the  inspiratory  and  expiratory  portions  of  the 
act,  the  sounds  following  each  other  so  closely  that  they  are  virtually 
continuous.  The  nearer  one  approaches  regions  of  the  production 
of  bronchial  sound,  whether  normal  or  abnormal,  the  more  distinct 
on  auscultation  becomes  the  pause  between  inspiration  and  expiration. 

The  RHYTHM  or  rate  of  recurrence  of  the  sounds  of  inspiration 
and  expiration  is  characterized  normally  by  regular  intervals. 

ORIGIN. — Opinions  vary  as  to  the  precise  cause  of  the  sound  of 
vesicular  or  cell  breathing.  None  of  the  theories  proposed  have  re- 
ceived, as  yet,  demonstration  by  positive  proofs. 

According  to  Laennec  and  others,  the  sound  is  produced  by  the 
entrance  of  the  air  into,  and  its  expulsion  from,  the  air-cells — by 
the  friction  of  the  air  in  its  passage  in  and  out  of  the  bronchioles 
and  alveoli,  against  their  walls.  The  more  probable  hypothesis  of 
Baas,  Penzoldt,  and  perhaps  the  majority  of  writers  and  experiment- 
ers, attributes  the  vesicular  murmur  to  the  modified  laryngotracheal 
sound  transmitted  downward  with  reduced  force  and  increased  diffu- 
sion through  the  branching  and  diminishing  capacity  of  the  bronchial 
tubes,  and  softened  by  the  distant,  dissipating  effect  of  the  vibrating 
and  absorbing  spongy  vesicular  lung  tissue.  That  the  vesicular  breath 
sound  is  really  the  bronchotracheal  sound  modified  by  its  conduction 
and  prolongation  into  the  bronchial  ramifications  and  alveoli  may  be 
shown  in  the  fact  that  when  the  latter  are  deprived  of  air  by  the 
disease  products  in  consolidated  lung,  as  in  pneumonitis,  the  harsh 
tubular  breathing  is  transmitted  readily  to  the  chest  wall,  and  thus 
to  the  ear,  the  muffling  effect  of  the  air-cells  being  in  abeyance,  and 
the  intensifying  effect  of  the  solidified  lung  being  superadded.  At  the 
same  time,  it  cannot  be  truly  denied  that,  if  only  to  a  minor  degree, 
the  vibrations  at  the  terminal  portions  of  the  bronchi,  at  the  instant 
of  vesicular  dilation,  may  be  contributory  factors  in  the  production 
of  this  respiratory  murmur. 


150  PHYSICAL   DIAGNOSIS 

As  the  larger  bronchial  tubes  branch  off  into  the  smaller,  and  the 
latter  into  the  bronchioles,  not  only  is  the  harsh,  blowing  character 
of  the  bronchial  sound  softened  and  damped  by  the  consequent  diffu- 
sion and  interfering  reflection  of  weakened  and  superaddcd  aerial 
vibrations,  but  also  by  the  gradual  structural  changes  in  the  walls 
of  the  tubes.  That  is,  as  the  homogeneity  of  structure  of  the  larger 
bronchial  tubes,  with  their  cartilaginous  and  muscular  walls,  becomes 
lost  in  the  transition  to  the  elastic  membranous  bronchioles  and  alve- 
oli, the  pronounced  tubular  quality  and  intensity  become  diminished 
and  confused,  owing  to  the  loss  of  conductivity  of  the  tissue  vibrations 
of  the  latter  as  compared  with  the  former. 

The  reason  why  the  expiratory  sound  is  not  so  long  nor  so  loud 
as  the  inspiratory  is  probably  because  in  the  latter  instance  the  vibrat- 
ing current  of  air  is  directed  toward  the  auscultating  ear,  and  in  the 
former,  from  it.  This  is  augmented  by  the  fact  that  the  inspiratory 
movement  is  normally  more  energetic  than  the  expiratory;  it  is  the 
combination  of  muscular  and  atmospheric  force  in  the  one  case  against 
the  simple  recoil  and  relaxation  of  the  air  vesicles.  Again,  the  tension 
of  the  alveoli  during  inspiration  renders  the  breath  sound  louder  at 
this  time  because  of  the  greater  conductivity  of  their  tissue. 

NORMAL  VARIATIONS. — Quite  compatible  with  a  normal  state  of 
the  lungs,  there  are  certain  peculiarities  and  variations  of  vesicular 
breathing  which  need  to  be  recognized.  The  first  of  these  is : 

Age. — In  children  under  about  the  twelfth  year,  the  vesicular 
murmur  is  exaggerated,  harsher,  and  louder  than  in  adults  of  middle 
age.  This  increased  intensity  is  characteristic  of  the  expiration  as 
well  as  of  the  inspiration.  As  will  be  pointed  out  later,  lung  that  is 
doing  extra  or  compensatory  work,  because  of  another  portion  of  lung 
that  is  disabled  by  disease,  produces  an  exaggeration  of  the  vesicular 
breath  sound  which,  resembling  the  normal  quality  and  intensity  of 
the  breathing  of  childhood,  is  often  spoken  of  as  puerile  respiration. 
That  this  peculiarity  is  due  to  the  relatively  smaller  and  more  elastic 
vesicles,  with  consequent  larger  relative  proportion  of  bronchial  tissue, 
and  more  resistance  to  the  inspiratory  effort  calling  for  more  forcible 
action,  both  combining  to  roughen  the  murmur,  is  quite  obvious. 
Undoubtedly,  an  additional  factor,  passive,  is  the  very  trifling  oppo- 
sition to  the  transmission  of  sound  which  the  thin,  elastic  chest  walls 
of  young  children  offer. 

In  old  age,  on  the  other  hand,  the  intensity  of  the  vesicular  respi- 
ration is  diminished,  while,  owing  to  the  weakened  and  inelastic  con- 
dition of  the  lung,  the  inspiration  is  slightly  shortened  and  the 


AUSCULTATION  151 

expiration  a  little  prolonged,  the  alveoli  recoiling  tardily  and  slowly. 
Senile  respiration,  as  observed  in  healthy  old  people,  is  to  be  differ- 
entiated, however,  from  the  morbidly  weakened  respiration  in  the 
greater  length  of  the  expiratory  sound  of  the  former. 

Sex. — Generally,  the  total  respiratory  murmur  in  the  female  is 
louder  than  in  the  male,  especially  in  the  upper,  anterior  regions 
of  the  chest. 

Jt'et/ion  and  Side  of  the  Chest. — In  most  healthy  individuals  the 
sounds  are  more  distinct  and  intense  on  the  left  side,  and  particularly 
in  the  infraclavicular  region.  They  are,  of  course,  more  audible 
where  the  chest  walls  are  thinnest ;  hence,  they  are  clearer  anteriorly 
than  posteriorly,  over  the  axillary  and  infrascapular  regions  than  the 
mammary  and  scapular.  It  is  of  such  great  practical  importance, 
that  to  repeat  here  what  was  indicated  before  concerning  the  broncho- 
vesicular  character  of  the  breath  sounds  near  the  junction  of  the 
second  rib  with  the  sternum  on  the  right  side,  due  to  the  closely 
subjacent  bronchus,  is  not  at  all  irrelevant.  The  harsher  blowing  and 
more  prominent  expiratory  element  in  the  interscapular  region  must 
also  be  reiterated  in  this  connection.  The  vesicular  murmur  is  rela- 
tively weak,  too,  over  the  apices,  with  their  small  volumes  of  air 
capacity.  Not  only  increased  thickness  of  the  soft  parts,  as  in  obesity, 
but  also  massiveness  and  increased  convexity  of  the  ribs,  interfere 
decidedly  with  the  ready  transmissibility  of  the  vesicular  sounds. 

Rapidity,  Fulness,  and  Continuity  of  Respirations. — The  intensity 
of  the  respiratory  sounds  increases  directly  with  the  frequency  of  the 
breathings.  Also,  the  duration  of  both  inspiratory  and  expiratory 
sounds  is  increased  with  full  and  deep  respirations,  as  after  exercise 
or  excitement.  Marked  intensity  of  the  respiratory  murmur  may  be 
a  matter  of  temperament,  idiosyncrasy,  or  of  some  neurotic  disposi- 
tion, as  in  hysteria. 

A  jerky,  interrupted,  or  wavy  inspiration,  though  frequently  asso- 
ciated with  incipient  tuberculosis,  may  be  heard  as  a  special  peculiarity 
consistent  with  perfect  pulmonary  health.  It  occurs  in  certain  per- 
sons who  breathe  slowly  and  irregularly,  and  may  be  caused  to  dis- 
appear after  a  quick,  full  inspiration.  Physiologic  jerky  respiration 
is  heard  nearly  uniformly  over  the  lungs;  that  due  to  tuberculosis  is 
limited  to  a  small  area,  usually  one  or  other  apex.  It  may  be  found, 
also,  in  hysterical  persons,  and  in  whining  or  sobbing  children.  It  is 
recognized  by  the  inspiratory  murmur  occurring  in  a  series  of  short 
puffs,  with  scarcely  more  than  two  or  three  intermissions.  The  char- 
acter of  interrupted  breathing  may  be  simulated  by  pursing  the 


152  PHYSICAL    DIAGNOSIS 

lips  and  drawing  the  air  through  them  in  several  quick,  sudden 
draughts. 

Systolic  vesicular  breathing  refers  to  a  rhythmic  exaggeration  of 
the  respiratory  murmur,  principally  during  inspiration,  also  jerky  or 
puffy  in  quality,  coinciding  with  the  cardiac  contraction,  and  heard 
at  the  border  of  the  lung  near  the  heart.  As  the  lung  expands,  with 
the  alveoli  in  closer  contact  with  the  heart,  the  systolic  movements 
of  the  latter  cause  an  unequal  entrance  of  air  into  the  vesicles — a 
rhythmical  rush  corresponding  with  the  systole,  increasing  in  intens- 
ity up  to  the  end  of  inspiration,  and  rapidly  subsiding  at  the  begin- 
ning of  expiration. 

I  have  known  this  phenomenon  in  not  a  few  cases  to  be  mistaken 
for  a  valvular  heart  murmur,  either  by  students  or  by  examiners 
doing  rapid,  desultory  dispensary  work. 

Having  become  familiar  with  the  normal  sounds  of  respiration, 
and  with  their  normal  variations  and  peculiarities,  one  is  ready  to 
apprehend  and  analyze  the  pathologic  sounds. 


SOUNDS  OF  ABNORMAL   RESPIRATORY  CONDITIONS 

Auscultation  determines,  first  of  all,  the  pathologic  modifications 
of  the  breath  sounds,  and  essentially  of  their  attributes  of  intensity, 
rhythm,  and  quality.  The  examination  is  practically  confined  to  those 
regions  of  the  chest  which  cover  the  lungs;  that  is,  where  vesicular 
respiration  or,  as  over  the  right  apex  or  interscapular  region,  bron- 
chovesicular  breathing  is  normally  audible.  So  long  as  we  hear  the 
vesicular  respiratory  murmur  over  the  chest,  we  are  assured  that  the 
subjacent  air  vesicles  are  permeable,  as  well  as  that  the  supplying 
bronchial  tubes  must  likewise  be  free. 

The  student's  first  aim  is  to  satisfy  himself  that  he  has  eliminated 
the  confusing  effect  of  the  heart  sounds;  that  he  is  listening  exclu- 
sively and  definitely  to  the  respiratory  murmur;  and  then,  that  he 
can  clearly  distinguish  the  sounds  corresponding  to  the  two  acts  of 
respiration.  The  latter  may  be  facilitated  by  placing  the  hand  upon 
the  thorax  or  epigastrium. 

Having  fixed  the  attention  on  the  inspiratory  and  expiratory 
sounds,  it  is  of  prime  importance  to  analyze  carefully  their  (a)  loud- 
ness  or  intensity;  (&)  their  relative  lengths,  and  the  presence  and 
duration  or  absence  of  a  pause  between  them;  (c)  the  character  or 
quality  of  both  sounds;  (d)  the  pitch,  especially  of  the  expiratory 
sound. 


AUSCULTATION  153 

(A)   Pathologic  Modifications  of  the   Vesicular  Breathing 

Alterations  of  Intensity.  (1)  INTENSITY  INCREASED:  Exagger- 
ated, Compensatory,  Vicarious,  or  Puerile  Breathing. — Exaggerated 
respiration  differs  from  the  normal  in  being  louder,  and  at  the  same 
time  longer  (for  it  is  quite  common  to  have  two  or  more  attributes 
suffer  alteration  simultaneously).  The  increased  intensity  affects  both 
the  inspiratory  and  expiratory  sounds,  but  is  especially  noticeable  of 
the  expiratory,  as  normally  this  is  scarcely  heard  at  all.  The  inspira- 
tory sound  is,  to  be  sure,  predominantly  much  louder,  and  the  in- 
creased audibility  of  expiratory  sound  is  partly  because  of  its  longer 
duration.  On  account  of  its  superficial  resemblance  to  pathologic 
bronchovesicular  breathing,  the  unskilled  examiner  may  erroneously 
attribute  morbid  changes  to  a  portion  of  lung  that  is  simply  over- 
acting. An  important  element  in  the  differentiation  here  lies  in  the 
fact  that  while  the  respiratory  murmur  is  lengthened,  the  normal 
ratio  is  maintained ;  that  is,  the  duration  of  inspiration  to  expiration 
is  as  6  to  2  (normal,  3  to  1).  The  pitch  remains  unaltered.  The 
vesicular  quality,  though  harsher — like  the  puerile  respiration  of  chil- 
dren— nevertheless  lacks  the  bronchial  modification  indicative  of 
closure  of  the  alveoli ;  the  softer  vesicular  quality  is  still  preserved. 

The  immediate  cause  of  exaggerated  or  intensified  breath  sound 
is  increased  functional  activity  of  the  whole  or  a  part  of  a  lung, 
compensatory  or  supplementary  to  restricted  or  abolished  action  due 
to  disease  of  the  opposite,  or  another  part  of  the  same  lung.  Hence, 
the  discovery  of  exaggerated  breathing  is  the  indirect  evidence  of 
some  morbid  pulmonary  condition  elsewhere. 

It  occurs  over  healthy  lung  tissue  adjoining  parts  where  the  smaller 
bronchial  tubes  are  partially  obstructed  by  the  tumefaction  of  an 
acute  catarrhal  inflammation  of  the  mucous  membrane,  aggravated 
by  an  accumulation  of  sticky  mucus.  The  appearance  of  a  height- 
ened intensity  or  sharpness  of  the  inspiratory  sound  over  a  lung  apex 
may  be  the  first  auscultatory  evidence  of  a  beginning  tuberculous 
bronchitis — hardly  more  than  a  tiny  tubercle  projecting  into  the  lumen 
of  a  bronchiole  so  as  to  cause  compensatory  increase  of  force  of 
breathing  in  the  surrounding  vesicles.  Unilateral  exaggeration  of  the 
breath  sounds  is  typically  heard  in  cases  of  severe  pneumonitis  affect- 
ing the  opposite  lung,  or  of  -compression  of  the  other  lung  by  a  large 
pleuritic  effusion.  Local  intensification  of  the  .vesicular  respiratory 
murmur  may  be  present  over  the  upper  lobe  of  a  lung  that  is  relaxed 
in  its  lower  portion  by  being  floated  up  by  a  small  or  moderate  pleural 


154  PHYSICAL   DIAGNOSIS 

effusion,  or  over  either  the  upper  or  lower  lobe  when  the  other  is 
the  seat  of  a  pneumonic  consolidation.  Again,  in  tuberculous  consoli- 
dation of  one  apex,  exaggerated  vesicular  breathing  of  the  opposite 
apex  is  commonly  noted. 

Finally,  it  should  be  mentioned  that  exaggerated  breathing  over 
the  upper  portion  of  both  lungs  is  a  frequent  accompaniment  of 
tightly  laced  women. 

(2)  INTENSITY  DIMINISHED:  Weak,  Shallow,  or  Senile  Breath- 
ing. — This  is  a  soft  and  distant  degree  of  loudness,  a  simple  weakness 
of  the  intensity  of  the  vesicular  respiration.  At  the  same  time,  the 
duration  of  both  inspiratory  and  expiratory  sounds  is  proportionately 
shortened.  The  inspiratory  sound  is  distinctly  weakened,  and  the 
expiratory  sound  is  practically  inaudible. 

The  numerous  causes  of  feeble  respiration  may  be  considered 
under  three  heads,  as  follows:  (1)  Those  which  interfere  with  the 
perfect  transmission  of  the  breath  sounds;  (2)  those  which  prevent 
full  expansion  of  the  lungs,  (3)  or  which  diminish  the  elasticity 
of  the  vesicles. 

Of  the  first  condition,  we  have  edematous  thickening  of  the  chest 
walls,  obesity,  or  some  solid  tumor;  principally,  however,  it  is  due 
to  some  thickened  or  adherent  pleura,  or  to  a  moderate  plcural  liquid 
effusion;  in  the  case  of  the  latter,  the  faintness  of  the  respiratory 
murmur  is  usually  on  one  side  of  the  chest,  while  on  the  unaffected 
side  relative  exaggeration  of  breathing  may  be  heard.  Pneumothorax 
(air  in  the  pleura!  sac)  of  moderate  degree,  or  circumscribed  by 
adhesions,  may  also  intervene  between  the  lung  and  chest  wall,  so  as 
to  weaken  the  breath  sounds  without  modifying  the  vesicular  quality. 

Secondly,  conditions  which  interfere  with  expansion  of  the  lung 
(besides  those  which  are  referred  to  in  the  preceding  paragraph,  and 
which  so  act  indirectly)  are  mainly  the  following:  (a)  Obstructions 
of  the  larynx,  trachea,  or  a  bronchus,  as  from  foreign  body  within, 
pressure  of  a  tumor  or  aneurism  from  without,  inflammatory  or  mem- 
branous swelling  or  edema  of  the  larynx  or  trachea,  accumulations 
of  mucus  and  pus,  and  catarrhal  thickening  of  the  bronchial  mucosa 
in  bronchitis  and  bronchiolitis ;  also  from  spasm  of  the  larynx,  and 
of  the  bronchioles  in  asthma,  and  from  partial  filling  of  the  alveoli  in 
pulmonary  edema.  (&)  Deficient  respiratory  action,  as  from  rigidity 
of  the  thorax,  paralysis  of  the  diaphragm  or  thoracic  muscles,  painful 
conditions  such  as  pleuritis,  pleurodynia,  or  intercostal  neuralgia, 
and  general  peritonitis;  again,  from  mechanical  restraint  due  to 
abdominal  enlargements,  as  ascites,  tympanites,  and  large  tumors. 


AUSCULTATIOX  155 

In  the  third  place,  diminished  elasticity  of  the  vesicular  tissue 
from  the  weakness  of  permanent  overdistention  is  characteristic  of 
emphysema,  in  which  feehle  respiratory  murmur  is  a  constant  physical 
sign.  In  the  first,  or  congestive,  stage  of  acute  lobar  pneumonitis, 
also,  shallow  breathing  may  be  noted. 

In  the  last-named  affection  the  weak  breathing  is  heard  on  both 
sides  of  the  chest.  Unilateral  diminution  of  loudness  is  a  feature 
of  partial  occlusion  of  one  or  other  bronchus,  pleural  effusion,  and 
the  early  stage  of  pneumonitis,  although  in  cases  of  the  latter,  as  with 
tuberculous  consolidation,  the  diminution  may  be  only  local,  depend- 
ing upon  the  extent  of  involvement.  Where  the  movements  of  the 
thorax  as  a  whole  are  restricted,  as  from  the  conditions  other  than 
emphysema  mentioned,  bilateral  enfeeblement  of  respiratory  sounds 
may  be  observed.  In  connection  with  the  painful  conditions,  as 
pleuritis  of  the  dry,  plastic  variety,  and  pleurodynia,  the  deficiency 
of  breathing  may  vary  and  thus  assume  an  intermittent  form. 

(3)  ABSENT  OR  SUPPRESSED  BREATHING. — This  occurs  over  large 
pleuritic  exudations,  as  of  pus,  serofibrin,  and  blood;  over  diffuse, 
closed  pneumothorax,  with  complete  occlusion  of  either  bronchus,  and 
over  great  thickening  of  the  pleura,  or  of  the  lung  in  fibroid  phthisis. 
The  breath  sounds  may  be  abolished  also  from  any  aggravation  of  the 
conditions  which  produce  mere  weakening  of  the  vesicular  respiration. 
Obviously,  in  the  complete  infiltration  of  the  air-cells  which  follows 
the  congestive  stage  of  pneumonitis,  and  in  extensive  tubercular  de- 
posit, the  abolition  of  the  vesicular  murmur  is  due  to  its  replacement 
by  a  changed  type — bronchial  or  bronchovesicular — of  breathing. 

Alterations  of  Rhythm. — These  have  to  do  with  disturbances  of 
the  regularity,  continuity,  and  relative  lengths  of  the  inspiratory  and 
expiratory  sounds,  and  of  the  pause  between  them. 

(1)  INTERRUPTED,  JERKY,  OR  "COGWHEEL"  RESPIRATION. — The 
occurrence  of  this  kind  of  breathing  as  a  normal  variation  has  been 
referred  to  before.  Therefore,  too  much  importance  must  not  be  given 
to  it  as  to  its  diagnostic  value  in  pathologic  conditions,  and  yet  the 
discovery  of  it  over  a  lung  apex  should  awaken  suspicion  as  to  the 
presence  of  a  tuberculous  bronchiolitis  or  localized  pleuritis. 

Usually  the  inspiratory  sound,  instead  of  being  even  and  continu- 
ous, is  broken  into  a  series  of  puffs  separated  by  irregular,  short  in- 
tervals, hence  the  term  "  cogwheel "  respiration.  It  is  at  the  same 
time  rough  or  harsh  in  incipient  tuberculosis.  Aside  from  its  occur- 
rence in  nervous,  chilly,  or  fatigued  persons  (from  irregular  muscu- 
lar action),  it  should  not  be  confused  with  the  cardiorespiratory 


156  PHYSICAL    DIAGNOSIS 

whiffing  sound  associated  with  excited  cardiac  movements.  The  latter 
is  more  likely  to  be  localized  adjacent  to  and  a  little  beyond  the  left 
border  of  the  heart ;  in  cases  of  the  former,  the  interrupted  breathing 
is  generalized.  I  have  found  the  cardiopulmonary  variety  of  puffy 


Weak  or  senile.  Normal.  Harsh  or  puerile. 


A 


A. 


Harsh  with  prolonged  Wavy.  Jerking  or  interrupted 

expiration.  (Cog-wheel). 

FIG.  38. — DIAGRAMMATIC  REPRESENTATION  OF  THE  VARIETIES  OF  VESICULAR  BREATH- 
ING. The  dotted  part  of  down  line  represents  the  inaudible  part  of  expiration. 
After  Wyllie.  (Gibson  and  Russell.) 

respiration  to  be  a  trifle  sharper,  and  prompter  in  its  onset  than  that 
due  to  apical  bronchiolitis. 

Pathologic  wavy  or  jerky  breathing  is  most  commonly  the  result 
of  tubercles  protruding  from  the  wall  of  an  infiltrated  bronchiole,  or  of 
the  presence  of  tenacious  mucus,  both  interfering  either  with  the 
continuous  .passage  of  the  air  current  directly,  or  causing  adjacent 
lobules  to  expand  at  different  times.  Associated  with  other  confirma- 
tory physical  signs,  interrupted  respiration  thus  becomes  an  indica- 
tion of  early  tuberculosis,  localized  over  the  affected  apex.  The  same 
effect  upon  the  breath  sound  may  be  produced  there  by  a  circum- 
scribed area  of  adhesive  pleuritis  of  tuberculous  origin. 

As  a  case  of  tuberculosis  progresses,  the  type  of  breathing  changes 
to  the  bronchovesicular,  with  prolonged  expiration,  when  the  sound 
of  the  latter  may  also  be  wavy,  or  interrupted  and  jerky. 

In  the  first  stage  of  acute  plastic  pleuritis,  in  pleurodynia  and 
intercostal  neuralgia,  cogwheel  respiratory  rhythm  may  be  heard  on 
the  side  affected. 

(2)  LENGTHENED  INTERVAL  BETWEEN  INSPIRATION  AND  Exriiu- 
TION. — Instead  of  the  inspiratory  and  expiratory  sounds  succeeding 
each  other  with  the  seeming  closeness  of  continuity,  pathologic  pro- 
longation of  the  momentary  pause  between  them  may  be  discovered; 
hence  the  term  "divided  respiration"  (Walshe).  When  this  occurs, 


AUSCULTATION  157 

it  is  either  because  the  inspiratory  sound  is  shortened,  unfinished,  or 
because  the  expiratory  sound  is  delayed,  deferred. 

Lengthened  pause  from  delay  in  the  oncoming  of  the  expiratory 
sound  is  characteristic  of  emphysema,  with  its  impaired  elasticity  of 
the  vesicles,  the  first  part  of  the  expiratory  act  being  unaccompanied 
by  sound. 

Shortened  inspiratory  sound  is  observed  in  cases  of  marked  con- 
solidation of  the  lung,  as  from  pneumonitis  or  tuberculosis,  the  in- 
spiratory sound  ceasing  before  the  chest  expansion,  the  breathing 
being  harsh  or  bronchial.  More  frequently,  however,  we  meet  with 
a  deferred  inspiration  in  emphysema,  also,  the  inspiratory  movement 
of  the  chest  commencing  before  the  sound  becomes  audible. 


Normal.  Shortened  inspiration.  Delayed  expiration. 

FIG.  39. — DIAGRAMMATIC  REPRESENTATION  OF  PROLONGED  PAUSE. 

(3)  PROLONGED  EXPIKATION. — As  the  normal  expiratory  sound  is 
so  short  that  it  is  scarcely  more  than  audible,  any  relative  increase 
in  its  duration  must  necessarily  be  abnormal.  The  qualifying  term 
relative  is  used  with  emphasis,  indicative  of  the  disproportionate 
lengthening  of  the  expiratory  sound,  so  that  the  normal  ratio  of  in- 
spiratory to  expiratory  duration,  3  to  1,  becomes  3:2,  as  in  broncho- 
vesicular  breathing,  or  3:3,  as  in  bronchial  breathing.  Even  the 
prolonged  expiration  of  exaggerated  respiration,  where  the  normal 
ratio  of  duration  is  maintained  by  a  corresponding  lengthening  of 
inspiration,  hints  at  the  presence  of  disease  in  some  other  portion 
of  lung. 

But  the  significance  of  prolonged  expiratory  sound  is  not  specific 
or  independent;  on  the  other  hand,  it  depends  upon  its  amount  of 
relative  increase,  and  associated  alterations  of  pitch  especially,  and 
of  quality.  Thus,  when  harsh  and  tubular  in  quality,  high  in  pitch, 
and  as  long,  or  even  a  little  longer,  than  the  inspiratory  sound,  having 
a  ratio  of  3  to  4,  it  means  that  the  vesicles  of  the  area  involved  are 
filled  with  a  tuberculous  or  inflammatory  deposit  of  nearly  or  quite 
lobar  size,  so  that  air  is  free  to  pass  in  and  out  of  the  bronchial  tubes 
only;  hence  the  sound  has  the  characteristics  of  bronchial  breathing. 
Again,  with  a  still  longer  relative  increase  in  the  expiration,  as  1:3, 
but  with  feeble  vesicular  quality  of  low  pitch,  as  is  heard  over  both 


158  PHYSICAL    DIAGNOSIS 

lungs  in  emphysema,  the  cause  of  the  prolongation  resides  in  the  loss 
of  elasticity  due  to  a  permanent  and,  as  it  were,  paretic  condition  of 
the  dilated  alveolar  walls.  Moreover,  in  emphysema  we  have  another 
cause  for  the  prolonged  expiratory  sound  in  the  obstruction  to  the  free 
egress  of  air  on  account  of  the  diffuse  bronchial  catarrh  nearly  always 
associated.  Lastly,  emphysema  is  the  only  condition  in  which  the 
prolonged  expiration  is  low  in  pitch;  all  other  causes  of  this  change 
produce  at  the  same  time  elevated  pitch,  with  the  occasional  exception 
of  a  deeply  seated,  lax-walled  cavity  in  the  lung,  the  breath  sounds 
over  which  may  have  a  low-pitched,  hollow  quality. 

By  way  of  antithesis  and  association,  the  two  principal  physical 
changes  in  the  lungs  may  be  placed  thus : 

Consolidation  Emphysema 

Vocal  fremitus;  increased.  Diminished. 

Percussion ;  dulness,  high-pitched.  Hyperresonance,  low-pitched. 

Auscultation;    expiratory    sound  Also    prolonged    expiration,    but 

prolonged,  high-pitched,  harsh,        low-pitched,  feeble,  vesicular. 

bronchial. 

When  due  to  asthma,  the  prolonged  expiratory  sound  may  be 
obscured  by  the  loud,  dry,  wheezing  or  whistling  sounds  or  rales, 
because  of  spasm  and  mucous  clogging  of  the  bronchioles. 

The  occurrence  of  slightly  lengthened  and  higher-pitched  expira- 
tory murmur  over  an  apex,  with  or  without  adventitious  rales,  is  one 
of  the  positive  physical  signs  of  beginning  tubercular  infiltration 
there — bronchovesicular  breathing. 

A  harsh,  prolonged  expiratory  breath  sound  may  also  be  the  re- 
sult of  a  severe  general  bronchitis,  as  in  children  who  have  had 
measles  or  whooping-cough  preceding  it,  or  in  very  old  people  subject 
to  "  winter  cough,"  and  having  weak  hearts.  The  extensive  bronchial 
catarrh  is  distinctly  indicated  by  the  evident  obstruction  to  the  exit  of 
air  currents  that  apparently  have  difficulty  in  entering  the  vesicles. 

Alterations  of  Pitch. — The  pitch  of  normal  vesicular  respiration 
being  low,  all  elevations  of  this  attribute  point  to  bronchovesicular 
or  bronchial  modifications,  according  to  the  extent  of  tissue  consoli- 
dated. The  change  is  most  significant  in  relation  to  the  expiration, 
which  is  always  simultaneously  prolonged  with  the  abnormally  high 
pitch.  The  low-pitched  cavernous  breathing  sometimes  met  with  also 
has  a  quality  of  sound  that  is  not  easily  confused  with  the  vesicular 
type. 


AUSCULTATION  159 

Alterations  of  Quality. — Wherever  the  normal  vesicular  murmur 
is  replaced  by  another  quality  or  type  of  breath  sound,  the  recognition 
and  discrimination  is  made  by  an  analysis  of  the  combination  of  the 
other  changed  elements.  The  name  given  to  the  pathologic  substitute 
for  the  normal  vesicular  respiration  is  of  secondary  importance,  and 
may  be  only  a  vague  and  convenient  intimation  of  the  actual  deter- 
mining factors.  In  short,  we  make  the  diagnosis  of  morbid  physical 
changes  in  the  lung  by  a  careful,  penetrating  comparison  of  the 
changed  attributes  rather  than  by  an  endeavor  to  embrace  and  de- 
scribe them  under  a  name,  either  to  oneself  or  to  others.  One 
should  rigidly  and  critically  define  the  expressions  used  below  in  terms 
of  the  altered  conditions  of  rhythm,  intensity,  and  pitch  just  given 
in  the  preceding  paragraphs. 

(1)  BROXCHOVESICULAR,  HARSH,  OR  KUDE  RESPIRATION;  INDE- 
TERMINATE BREATHING. — In  this  variety  of  breathing,  the  soft, 
breezy  quality  of  the  normal  vesicular  sound  is  lost  and  exchanged 
for  a  harsher,  sharper,  more  blowing  sound,  more  marked  in  expiration 
than  in  inspiration.  And  yet  the  sounds  of  both  are  not  as  rough 
and  tubular  as  in  bronchial  breathing.  Naturally,  there  may  be 
many  degrees  of  variation  between  true  vesicular  and  bronchial  respi- 
ration ;  therefore  the  terms  "  indeterminate "  or  "  transition,"  some- 
times applied  to  this  type,  especially  by  European  clinicians.  It  is 
detected  over  the  small  areas  of  condensation  of  lung,  not  too  deeply 
situated,  where  it  is  caused  by  the  generally  sharp  and  harsh  respi- 
ration, and  particularly  by  the  relative  prolongation  and  elevation 
of  pitch  of  the  expiratory  sound. 

The  physics  of  the  pathologic  source  of  the  bronchovesicular 
breathing  is  easily  understood:  A  certain  number  of  vesicles  infil- 
trated with  firm  exudate  form  a  lobular  area  of  solidification  of  better 
conductivity  for  the  included  bronchioles,  but  not  large  enough  to 
prevent  the  surrounding  open  vesicles  from  subduing  the  tubular, 
bronchial  harshness  of  more  extensive  areas  of  consolidation.  Bron- 
chovesicular breathing  may  be  heard  also  over  large  consolidations 
with  some  thickness  of  unaffected  lung  intervening. 

If  bronchovesicular  respiration  be  persistently  audible  at  one  apex, 
especially  the  left,  while  at  the  other  ordinary  vesicular  respiration 
remains,  incipient  tuberculous  infiltration  may  be  inferred,  the  inde- 
terminate breathing  being  produced  partly  by  mucous  obstruction  of 
some  of  the  bronchioles  or  smaller  bronchi,  as  well  as  the  restricted 
expansibility  of  the  alveoli.  Right  here  the  physiologic  difference 
between  the  two  sides  must  not  be  forgotten — that  at  the  right  apex, 


160  PHYSICAL    DIAGNOSIS 

in  the  supraclavicular  and  .supraspinous  regions,  bronchovesicular 
breath  sound  is  normal.  This  is  particularly  noticeable  during  quiet 
breathing  in  robust  and  muscular  individuals,  the  air-current  enter- 
ing the  vesicles  so  weakly  and  the  thick  thoracic  tissues  transmitting 
its  characteristics  so  slightly  that  the  bronchial  element  is  a  little 
predominant,  and  the  vesicular  character  becomes  fully  brought  out 
only  with  deep  respirations. 

Bronchovesicular  breathing  may  be  indicative  of  patches  of  col- 
lapsed lung  (atelectasis)  in  the  acute  capillary  bronchitis  of  children. 
Similarly,  it  is  found  over  small  areas  of  bronchopneumonitis,  espe- 
cially in  the  infrascapular  regions  of  both  sides,  in  the  very  young 
and  the  aged.  In  the  atypical  pneumonites  or  pulmonary  congestions 
complicating  influenza  ("grip"),  the  occurrence  of  indeterminate 
breathing  is  almost  constant.  Cases  of  frank,  typical  lobar  pneu- 
monitis  in  adults,  also,  in  the  first  or  congestive  stage,  give  rise  to 
bronchovesicular  respiration. 

The  differential  physical  diagnosis  between  simple  exaggerated 
breathing  and  the  bronchovesicular  variety  is  of  extreme  practical 
importance,  and  may  be  a  matter  of  difficulty,  doubt,  and  error  to 
the  clinician  of  limited  experience  as  well  as  to  the  more  excusable 
student  tyro.  The  superficial  resemblance  which  the  two  types  of 
respiratory  sound  have  to  each  other,  and  which  may  confuse  the 
inexperienced,  lies  in  the  increased  loudness  and  increased  length  of 
the  inspiratory  and  expiratory  sounds.  But  the  inspiratory  element 
of  bronchovesicular  breathing  has  a  quality  of  sharpness,  of  dry  harsh- 
ness, suggestive  at  once  of  a  small  area  of  fine-calibered  tubes  instead 
of  the  softer,  more  breezy  loudness  suggestive  of  a  more  voluminous 
area  of  spongy,  elastic  air-cells.  More  distinctive,  however,  are  the 
differences  concerning  the  expiratory  sound.  While  this  is  prolonged 
in  both  the  exaggerated  and  bronchovesicular  breathings,  in  the  latter 
the  normal  ratio  is  broken ;  that  is,  as  pointed  out  before,  the  expira- 
tory sound  is  abnormal  in  its  relative  or  proportionate  length  to  the 
inspiratory  sound.  This  is  by  all  means  the  principal  differential 
sign.  Next  in  value  is  the  harsher,  higher-pitched  expiratory  sound. 

To  mistake  bronehovesicular  breathing  for  exaggerated  or  puerile 
breathing  is  to  assume  the  absence  of  a  diseased  portion  of  lung  where 
there  actually  is  disease;  to  reverse  the  error  is  to  assume  or  infer 
the  presence  of  a  small  area  of  consolidation  which  does  not  exist  in 
that  region,  but  either  adjacent  to  it  or  in  the  opposite  lung ;  perforce, 
to  fail  to  detect  either  type  of  respiration  is  to  fail  to  discover  either 
directly  or  indirectly  any  limited  area  of  solidification. 


AUSCULTATION  161 

(2)  BRONCHIAL,  TUBULAR  RESPIRATION. — Here  there  is  a  com- 
plete absence  of  the  vesicular  quality,  and  wherever  substituted  for 
the  latter  is  pathologic.  It  may  be  recognized  readily  by  comparing 
its  attributes  with  the  ever-present  normal  bronchial  breathing  heard 
over  the  trachea.  Indeed,  the  bronchial  breathing,  caused  as  it  is  by 
large  consolidations,  is  not  essentially  pathologic,  but  is  merely  the 
sound  of  the  deeply  seated,  normal  bronchial  breathing  heard  through 
the  pathologically  infiltrated  vesicles,  which  now  form  an  area  of 
good  conducting,  solid  tissue.  It  is  not  a  superadded  type  of  respira- 
tion; it  is  simply  an  abnormally  transmitted  normal  type. 

Distinct  bronchial  breathing  resembles  more  nearly  the  blowing 
sounds  heard  at  the  bifurcation  of  the  trachea.  It  is  rather  harsh, 
loud,  and  tubular,  but  not  quite  so  much  so  as  the  bruit  heard  over 
the  larynx.  Both  inspiration  and  expiration  are  higher  in  pitch  than 
of  vesicular  breathing,  the  expiration  frequently  even  higher  than  the 
inspiration,  depending,  on  the  whole,  upon  the  force  of  the  respiratory 
act  and  the  caliber  of  the  bronchial  tubes.  The  inspiratory  sound  is 
a  little  shorter  in  duration  than  the  inspiratory  act,  is  rhythmically 
separated  by  a  short  interval  from  the  expiratory  sound,  which  is 
longer  than  that  of  vesicular  breathing,  and  fully  as  long  as  the 
inspiratory  sound.  The  intensity  is  marked,  but  variable;  it  may 
have  the  harsh,  dry,  loud,  whiffing  character  simulated  by  blowing 
to  and  fro  through  a  metallic  tube,  as  over  a  densely  consolidated 
portion  of  lung  near  the  ear  of  the  auscultator,  and  conducting  the 
sound  from  a  few  large  tubes,  perhaps;  or  it  may  be  less  loud,  more 
diffuse,  over  moderately  consolidated,  less  superficially  situated  tissue, 
and  transmitted  from  a  number  of  smaller  tubes.  At  the  same  time 
it  should  be  noted  that,  while  in  the  former  instance  the  pitch  may 
be  lower  than  in  the  latter,  great  rapidity  of  respirations  may  cause 
a  higher  pitch  than  over  the  moderately  solidified  lung  with  softer 
bronchial  blow.  As  a  rule,  however,  the  higher  the  pitch  of  the  bron- 
chial breathing  the  more  intense  the  degree  of  consolidation,  exem- 
plified especially  in  the  most  acute  cases  of  lobar  pneumonitis,  while 
the  medium  pitch  is  more  characteristic  of  large  tuberculous  consoli- 
dations. Of  course,  the  larger  the  part  hepatized  (firmly  infiltrated, 
liver-like),  the  louder  the  bronchial  sound,  because  the  greater  the 
volume  of  bronchial  air-space  within. 

In  order  to  appreciate  the  diagnostic  significance  of  pathologic 
bronchial  respiration,  therefore,  it  is  necessary  to  realize  clearly  the 
following  fundamental  considerations :  Any  breathing  sound  heard  at 

all  means  open  bronchial  tubes;  a  vesicular  breathing  sound  means 
13 


162  PHYSICAL    DIAGNOSIS 

open  alveoli;  a  bronchial  sound  indicates  that  there  is  closed  vesicular 
lung  tissue  between  the  bronchial  tubes  and  the  ear  of  the  auscul- 
tator,  the  tidal  movement  of  air  being  prevented  either  by  exudation 
within  the  vesicles,  or  by  compression  from  without. 

(a)  As  intimated  before,  lobar  pneumonitis  is  the  typical  cause 
of  bronchial  breathing,  the  condensation  of  lung  tissue  involving  an 
extent  sufficiently  large  so  as  to  include  the  medium-sized  or  large 
bronchial  tubes,  bronchovesicular  respiration  resulting  when  only  the 
smallest  tubes  are  surrounded  by  relatively  smaller  areas  of  thick- 
ening. 

In  some  cases  of  pneumonia,  however,  owing  to  occlusion  of  the 
large  supplying  bronchus  or  of  some  of  the  smaller  tubes  (inflam- 
matory exudate;  mucus,  fibrin),  no  breath  sound  is  heard;  but  after 
a  loose  cough  the  tubes  become  pervious,  and  bronchial  breathing 
may  then  be  transmitted.  As  pneumonia  usually  attacks  the  lower 
lobes,  bronchial  respiration  heard  at  the  base  of  the  chest  posteriorly, 
and  up  to  a  little  above  the  angle  of  the  scapula,  in  an  acute  illness. 
signifies  pneumonia  most  frequently.  At  the  apex,  tuberculosis  is 
the  common  cause  of  bronchial  breathing  in  the  moderately  advanced 
cases,  although  apical  pneumonitis  may  rarely  be  present. 

Among  other  and  less  common  conditions  of  solidification  of  lung 
tissue  giving  rise  to  bronchial  breathing  are  chronic  fibroid  pneu- 
monia (phthisical  or  syphilitic),  hemorrhagic  infarcts,  and,  less  per- 
fectly and  under  favorable  circumstances,  central  pneumonitis  (fol- 
lowed by  more  marked  bronchial  breathing  usually  within  a  week, 
as  the  consolidation  extends  to  the  surface),  carcinomatous  and  other 
new  growths,  and  pulmonary  abscess  and  gangrene. 

(b)  Compression  of  the  lungs  by  a  large  pleuritic  effusion,  so  that 
the  vesicles  are  void  of  air  while  the  bronchi  remain  patulous,  gives 
rise  to  bronchial  breathing,  also.    It  is  in  the  majority  of  cases  dis- 
tant and  feeble,  except  near  the  spine,  where  the  lung  is  collapsed; 
it  is  also  more  decidedly  audible  at  the  upper  layer  of  the  fluid. 
Care  must  be  taken  that  distant  bronchial  respiration  be  not  mistaken 
for  bronchovesicular.     Directly   over   the  exudation  the   respiratory 
sounds  are  inaudible.     The  presence  of  a  pleuritic  effusion  compli- 
cating a  pneumonitis  will  have  the  effect  of  similarly  enfeebling  the 
underlying  bronchial  breathing  produced  by  the  consolidation,  the 
change  of  consistence  of  the  media  having  a  damping  effect. 

Pneumothorax  not  infrequently  causes  such  a  compression  of  the 
lung  as  to  produce  bronchial  breathing  heard  best  between  the  shoul- 
ders. Partial  collapse  of  lung  may  also  make  pronounced  the  bron- 


AUSCULTATION  163 

chial  element  due  to  large  pericardial  effusions,  large  aneurisms,  great 
enlargement  of  the  heart,  and  the  pressure  of  malignant  growths 
within  the  pleural  sac. 

XOTE. — It  may  not  be  amiss  to  repeat  here  the  caution  not  to 
infer  the  presence  of  pathologic  bronchial  breathing  owing  to  the  ready 
transmission  of  nasopharyngeal  respiration.  This  fallacy  may  be 
obviated  by  requesting  the  patient  to  breathe  deeply,  but  continuously 
and  unconstrainedly.  It  is  extremely  unsatisfactory  to  have  patients, 
when  told  to  breathe  fully,  take  a  deep  inspiration,  then  hold  it  for 
a  few  seconds,  with  rigid  chest,  before  slowly,  and  often  very  much 
too  slowly,  allowing  expiration  to  take  place.  The  actual  presence 
of  physical  conditions  productive  of  bronchial  breathing  may  be  ob- 
scured in  this  way,  the  quality  of  the  expiratory  sound  unduly  sof- 
tened, and  the  true  relative  lengths  of  the  inspiratory  and  expiratory 
sounds  artificially  altered.  Instructing  the  patient  to  increase  the 
rapidity  of  the  respirations,  with  the  mouth  open,  will  usually  correct 
the  mode. 

Cavernous  respiration,  though  heard  over  cavities  of  the  lung,  and 
thus  significant  of  distinctive  conditions,  nevertheless  so  closely  re- 
sembles the  physical  characteristics  of  bronchial  breathing  that  it  may 
properly  be  considered  under  this  head. 

Laennec,  who  introduced  the  term,  described  cavernous  breathing 
as  giving  to  the  auscultating  ear  the  impression  of  a  bronchial  air- 
current  passing  promptly  into  a  large,  hollow  space.  Perhaps  the 
post-mortem  conditions  discovered  were  largely  influential  in  framing 
this  description.  The  distinguishing  characteristics  must  be  recog- 
nized in  the  modified  attributes  of  bronchial  breathing.  These  are 
noticed  to  develop  in  observing  the  course  of  a  case  of  progressive 
tuberculosis  of  the  lung,  in  passing  from  the  consolidation  stage  to 
that  of  cavity  formation. 

The  previously  harsh,  piping  quality  of  the  bronchial  breathing 
becomes  softer  and  hollow;  the  pitch  is  low,  especially  of  the  expira- 
tory sound — a  distinguishing  feature,  according  to  the  elder  Austin 
Flint,  in  that  the  expiratory  sound  of  true  bronchial  respiration  is 
usually  higher  in  pitch  than  the  inspiratory  sound.  As  to  rhythm, 
the  expiratory  has  nearly  the  same  length  as  the  inspiratory  sound. 
Other  elements  of  contrast  which  aid  in  physical  diagnosis  are  as 
follows:  Cavernous  breathing  seems  remote  from  the  examiner's  ear, 
less  intense,  while  bronchial  breathing  is  more  distinct  and  super- 
ficial; the  former  is  heard  over  a  more  limited,  circumscribed  area, 
the  latter  over  a  diffuse,  irregularly  outlined  area ;  lastly,  the  produc- 


164  PHYSICAL    DIAGNOSIS 

tion  of  the  cavernous  breath  sounds  is  slower,  retarded,  that  of  the 
bronchial  more  prompt  and  decided. 

These  points  of  differentiation  are  observable  mostly  where  the 
simple  condition  of  a  globular  cavity  with  flaccid  walls  exists,  large 
enough,  superficial  enough,  and  in  communication  with  a  bronchial 
tube.  In  general,  and  other  things  being  equal,  the  intensity  of  the 
cavernous  respiratory  sound  depends  upon  the  situation  and  size  of 
the  pulmonary  excavation,  the  caliber  of  the  communicating  bronchus, 
the  freedom  from  occluding  exudate,  and  the  energy  of  the  respira- 
tory act. 

In  the  event  of  the  cavity  being  surrounded  by  solidified  lung,  as 
is  quite  frequently  the  case,  before  the  focus  of  caseation  and  excava- 
tion has  extended  far,  the  bronchial  and  cavernous  characteristics  are 
so  intermingled  (broncho cavernous  breathing)  that  it  becomes  diffi- 
cult to  determine  precisely  the  actual  physical  changes.  Again,  should 
a  sufficient  thickness  of  healthy  vesicular  tissue  lie  between  the  cavern 
and  the  chest  wall,  the  bronchial  quality  of  the  respiration  in  the 
cavity  loses  its  distinctive  character  in  the  feeble  conducting  power 
of  the  alveolae  (vesiculocavernous  breathing).  And  finally,  cavernous 
breathing  may  be  weakened  by  temporary  narrowing  or  occlusion  of 
the  bronchus  leading  to  the  cavity,  or  by  a  partial  filling  of  the  latter 
with  muco-pus,  or  lost  by  complete  plugging  of  the  bronchus  or  filling 
of  the  cavity;  in  either  instance,  the  typical  breathing  may  be  re- 
established after  cough  and  expectoration. 

Besides  the  commonest  cause  of  cavernous  respiration,  namely, 
tuberculosis  of  advanced  stage  (usually  at  the  apices),  it  may  be 
heard  over  cavities  the  result  of  abscess,,  gangrene,  cancer,  or  due 
to  a  dilated  bronchus. 

Although  of  rare  occurrence,  it  sometimes  happens  that  cavern- 
ous respiration  is  audible  in  the  absence  of  pulmonary  cavity.  This 
has  been  observed  in  certain  cases  of  consolidation  surrounding  <i 
large  bronchus  in  pneumonitis,  and  of  pulmonary  collapse  from  pleu- 
ritic effusion,  the  subsequent  course  disproving  excavation  of  the  pul- 
monary parenchyma  by  the  disappearance  of  the  signs  with  recovery. 

(3)  AMPHORIC  KESPIRATION. — This  has  a  metallic,  echoing,  hol- 
low, or  blowing  quality,  and  therefore  is  more  easily  distinguished 
than  the  cavernous  respiration.  As  the  appellation  indicates  (<nn- 
phora,  a  jar),  it  may  be  imitated  by  blowing  gently  across  the  mouth 
of  an  empty  bottle  or  jar.  Amphoric  breathing  is  analogous  to  the 
amphoric  resonance  obtained  on  percussion  over  large,  empty,  dense- 
walled  pulmonary  cavities. 


AUSCULTATION 


165 


In  some  cases  amphoric  breathing  is  quite  loud ;  in  others  it  may 
be  audible  only  on  deep  or  forced  breathing.  The  pitch  varies  ac- 
cording to  the  volume  of  contained  air,  and  the  tension  of  the 
cavity  walls;  the  larger  the  lower  the  pitch,  and  the  tenser  the 


CAVITY   WITH 

SMOOTH,   FIRM 

WALLS 


AMPHORIC   BREATHING 
PECTORILOQUY 

OFTEN 
BRONCHIAL  BREATHING 


CAVITY 


BRONCHIAL  OR 
CAVERNOUS    RESPIRA- 
TION 


PLUGGED  BRON- 
CHUS, WITHOUT 
CONSOLIDATION 


ABSENT  VESICULAR 
BREATHING 

LESSENED  VOCAL  RES- 
ONANCE 


PLUGGED    BRON- 
CHUS, WITH 
CONSOLIDATION 


ABSENT  BRONCHIAL 
RESPIRATION 

ABSENT  VOCAL  RESO- 
NANCE 


DEEP 
CONSOLIDATION 


BRONCHO  -  VESICULAR 
BREATHING 

INCREASED  VOCAL  RES- 
ONANCE 


PARTIAL 
CONSOLIDATION 


BRONCHO  -  VESICULAR 
BREATHING 

INCREASED  VOCAL  RES- 
ONANCE 


COMPLETE 
CONSOLIDATION 


BRONCHIAL   RESPIRA- 
TION 

BRONCHOPHONY  OR 
PECTORILOQUY 


CONSOLIDATION 
WITH    EFFUSION 


DISTANT    BRONCHIAL 

BREATHING 


FIG.  40. — SCHEMATIC  DIAGRAM  OF  THE  VARIETIES  OF  BREATHING  AND  VOCAL  RES- 
ONANCE IN  DISEASE.     (Butler.) 


higher  the  pitch,  although  the  walls  are  characteristically  distended 
and  do  not  collapse  with  expiration,  as  is  so  common  with  the  lax- 
walled  cavities  eliciting  cavernous  breathing.  While  the  pitch  of 
amphoric  respiration  is  slightly  higher  than  that  of  cavernous,  it  is 
lower  than  bronchial  respiration;  and  further,  the  pitch  of  the  ex- 
piratory sound  is  a  little  lower  than  of  the  inspiratory.  The  amphoric 
quality  may  accompany  both  or  either  of  the  sounds,  but  is  espe- 
cially distinct  during  expiration. 

Causes. — Amphoric  breathing  is  always  pathologic,  and  due  either 
to  a  pulmonary  or  pleural  air-cavity  communicating  with  a  bronchus, 
in  the  latter  case  producing  what  is  known  as  open,  circumscribed 
pneumothorax. 

Although  this  variety  of  abnormal  respiratory  sound  is  probably 
heard  more  frequently  as  produced  by  pneumothorax,  the  conditions 


166  PHYSICAL   DIAGNOSIS 

of  its  occurrence  in  connection  with  pulmonary  excavation  will  be 
considered  first,  because  of  their  physical  similarity  to  cavernous  res- 
piration. 

(a)  To  give  rise  to  amphoric  respiration  the  cavity  in  the  lung 
must  be  of  considerable  size  (of  an  orange  or  fist),  have  tense,  firm, 
nearly  uniform  walls  in  thickness  and  density,  smooth  upon  their 
interior ;  have  communication  with  a  large  bronchus,  practically  empty 
of  exudate,  and  superficial  in  location.  It  is  only  in  cavities  of  large 
dimensions  that  amphoric  echo  is  produced,  whether  by  the  free  to- 
and-fro  movement  of  air  in  and  out  of  the  chamber,  or  by  the  factor 
of  consonance — that  is,  the  intensification  of  the  normal  breath 
sounds  in  their  transmission  through  the  cavity,  which  acts  as  a 
resonator.  Very  likely  the  latter  explanation  holds  in  a  majority  of 
instances,  for  the  restricted  movement  of  the  chest  wall  correspond- 
ing to  cavities,  as  well  as  to  a  pneumothorax,  would  indicate  that  the 
entrance  and  exit  of  air  is  hardly  forcible  enough  to  develop  amphoric 
breathing.  Indeed,  in  cases  of  pneumothorax,  the  affected  side  may 
be  entirely  immobile  and  the  lung  tissue  collapsed,  so  that  here  am- 
phoric eclio  is  acquired  by  the  bronchial  breathing  in  its  passage 
through  the  pleural  air-chamber  to  the  surface  by  means  of  the 
fistulous  opening  in  the  lung. 

Again,  unless  the  walls  of  the  cavity  possess  a  nearly  uniform 
density  and  thickness  and  internal  smoothness,  the  sonorous  vibra- 
tions cannot  be  reflected  with  that  degree  of  regularity  needful  for 
the  formation  of  a  tone  really  musical  in  character  (Guttmann). 
Further,  the  walls  must  not  collapse  with  expiration,  as  in  cavern- 
ous respiration.  It  must  be  quite  obvious  that  the  communicating 
bronchial  tube  must  be  patulous  and  of  sufficient  caliber,  and  the  cav- 
ity contain  so  little  liquid  that  the  consonance  will  not  be  interfered 
with.  Large  cavities  usually  extend  so  near  the  surface  that  the  am- 
phoric sound  is  loudly  audible,  especially  anteriorly  and  at  the  middle 
height  of  the  thorax,  where  they  are  more  commonly  located,  rather 
than  at  the  base  or  apex. 

(6)  Amphoric  respiration  is  met  with  most  distinctly  in  cases 
of  pneumothorax,  provided  there  is  a  patent  pleural  opening  above 
the  surface  of  any  fluid  present,  that  it  communicates  with  a  large 
bronchial  tube,  and  that  the  lung  is  not  so  completely  collapsed  that 
no  air  can  possibly  enter  through  the  pleural  fistula;  in  many  cases 
the  ruptured  pleura  heals  before  total  collapse  ensues.  Here  the  per- 
sistence of  amphoric  echo  is  due  to  the  transmitted  breath  sounds 
through  the  lung  and  pathologic  pleural  air-chamber. 


AUSCULTATION  167 

(4)  METAMORPHOSING  BREATHING  (Seitz). — This  is  a  modi- 
fication of  bronchial  breathing,  especially  of  the  inspiratory  sound. 
The  first  third  of  inspiration  is  characteristically  harsh,  tubal,  blow- 
ing; this  harshness  then  suddenly  changes  to  a  softer  bronchial,  cav- 
ernous, or  amphoric  breathing,  which  lasts  throughout  expiration. 
Seitz's  metamorphosing  respiration  is  met  with  (rarely)  as  a  sign 
of  cavity  of  the  lung.  Its  physical  explanation  resides  in  the  fact 
that  there  is  a  narrowing  or  stenosis  of  the  bronchial  tube,  near  its 
entrance  into  the  cavity,  which  is  suddenly  overcome  by  a  vigorous  in- 
spiration, thus  either  dilating  the  orifice  or  expelling  plugging  mucus, 
or  both.  The  change  from  the  bronchial  to  a  cavernous  type  of 
breathing  may  be  accompanied  by  rales,  due  to  the  disturbance  of 
liquid  in  the  cavity.  A  divided  inspiration  is  an  inconstant  sign 
of  pulmonary  cavern ;  but  when  repeatedly  made  out  is  a  distinctive 
sign. 


CHAPTER    VII 
AUSCULTATION   (Concluded) 

AUSCULTATORY   PHENOMENA  (Concluded) 

SOUNDS  OF  ABNORMAL  RESPIRATORY  CONDITIONS    (Concluded) 

(B)  Adventitious  Sounds 

Rales. — The  sounds  produced  by  the  act  of  breathing  may  be 
normal  or  abnormal.  The  sounds  which  are  now  to  be  considered 
are  always  abnormal,,  adventitious,,  and  not  modifications  of  a  natu- 
ral sound.  They  are  new  or  superadded  sounds,  either  intrapulmo- 
nary  or  pleural  in  origin,  accompanying,  or  obscuring,  or  even  sup- 
planting the  respiratory  sounds. 

As  soon  as  the  normally  smooth  mucous  membrane  becomes 
swollen  and  roughened  by  inflammation,  or  an  abnormal  increase 
in  the  production  and  accumulation  of  secretion  takes  place, 
either  viscid  or  fluid,  and  either  in  the  bronchial  tubes  or  air- 
cells,  adventitious  sounds  are  heard  along  with  the  respiratory 
murmur. 

The  accessory  sounds  which  are  generated  within  the  respiratory 
passages  and  lungs  are  called  rales  or  rhonchi,  the  term  rale  being 
the  one  commonly  used  to  designate  adventitious  sounds  produced 
in  the  bronchi,  alveoli,  and  cavities  of  the  lung.  Pleuritic  friction 
sounds  are  caused  by  affections  of  the  pleurae.  Unclassified  adven- 
titious sounds  are  the  metallic  tinkling  and  succussion  or  splashing 
sounds. 

Rales  (French,  denoting  a  rattling)  are  divided,  according  to 
their  quality  into  dry  and  moist;  according  to  the  location  of  their 
causation  they  may  be  laryngeal,  tracheal,  bronchial,  vesicular,  or 
cavernous.  Crepitation  or  crackling  may  be  dry  or  moist  (subcrepi- 
tant  rales). 

The  following  scheme  indicates  the  varieties  of  rales  usually  met 
with : 

168 


AUSCULTATION 


169 


KALES 

(1)  Lftr if n(/<'d I  and  Tracheal. 
(a)   Dry. 

(6)    Moist. 

(2)  Bronchial. 
(a)   Dry. 

1.  Sonorous,  large  or  coarse. 

2.  Sibilant,  small  or  fine. 

(I)   Moist. 

1.  Bubbling,  large  or  coarse 

mucous. 

2.  Bubbling,    small    or    fine 

mucous,     or     siibcrepi- 
tant. 

( 3 )  Vesicular. 
(a)   Dry. 

Crepitant,  or  fine  crackle. 

(6)   Moist. 

Fine,  soft  crackle,  "  mu- 
cous click"  (same  as 
subcrepitant). 

(4)  Cavernous. 

Gurgling,  large,  liquid. 


Croup,  tuberculosis,  laryn- 
gitis. 
"  Death-rattle." 


Acute  bronchitis  (larger 
bronchi  and  asthma). 

Acute  bronchitis  (smaller 
bronchi  and  bronchioles). 

Acute  bronchitis  (second 
stage),  chronic  bronchitis. 

Capillary  bronchitis,  edema 
of  the  lungs,  broncho- 
pneumonitis. 


First  stage  of  acute  lobar 
pneumonitis,  atelectasis. 

Softening  stage  of  small 
tubercular  deposits  in  the 
alveoli. 

Phthisical  cavities  partially 
filled  with  liquid  secre- 
tion. 


In  the  writing  of  Laennec :  "  Words  will  often  fail  me  to  express 
their  characters,  or  at  least  it  will  be  difficult  for  me  to  describe 
them  in  a  manner  sufficiently  accurate  to  give  a  correct  idea  to  him 
who  has  never  heard  them."  The  terms  "  dry  "  and  "  moist "  are 
used  simply  to  indicate  the  "  impression  made  on  the  observer's  mind 
as  to  whether  the  sound  is  produced  by  dry  or  moist  conditions." 

(1)  DRY  RALES  (Rhonchi). — These  sounds  are  commonly  pro- 
'duced  by  a  viscid,  scanty  exudate  in  the  bronchial  tubes,  or  by  a 
degree  of  narrowing  of  their  caliber  by  the  inflammatory  swelling 
of  a  bronchial  catarrh.  Although  there  is  some  moisture  present, 


170  PHYSICAL    DIAGNOSIS 

the  term  "  dry "  is  used  in  a  relative  sense,  as  the  impression  of 
bubbling  given  by  the  moist  rales  is  wanting;  the  exudate  is  drier 
and  scantier. 

Dry  rales  are  divided  according  to  their  pitch,  quality,  and  seat 
of  production  into  sonorous  and  sibilant.  They  have  distinct  dura- 
tion, whereas  moist  rales  are  instantaneous. 

Sonorous  rhonchi  are  low-pitched,  having  a  snoring,  purring,  or 
somewhat  groaning  character,  rather  loud  in  intensity,  and  produced 
usually  in  the  larger  bronchial  tubes.  These  deep-toned,  humming 
rales  may  occur  as  a  slight,  short,  single  rhonchus,  or  may  be  loud 
enough  to  be  audible  at  a  distance  from  the  chest,  and  numerous  and 
persistent  throughout  the  respiratory  act;  indeed,  they  may  obliterate 
the  breathing  sounds.  Because  of  the  fact  that  the  tough  mucus  is 
frequently  so  disposed  as  to  practically  change  the  bronchial  tubes 
into  wind  instruments,  the  rales  produced  take  on  a  musical.,  conso- 
nant, buzzing  quality.  Sometimes  a  very  coarse,  low-pitched  type  of 
sonorous  rale,  associated  with  hoarseness  and  stridulous  breathing, 
may  be  heard  in  connection  with  inflammatory  membranous  conditions 
of  the  larynx,  trachea,  and  main  bronchi,  and  may  communicate  a 
distinct  fremitus  to  the  hand  applied  to  the  chest. 

The  conditions  giving  rise  to  these  sonorous  rales  are  lessened 
caliber  from  tumefaction  of  the  mucous  membrane,  as  in  the  early 
stage  of  bronchitis;  the  presence  of  viscid  mucus  adhering  to  the 
swollen,  roughened,  even — in  the  very  intense  acute  cases — slightly 
corrugated  surface,  and  local  pressure  from  without  by  a  tumor  or 
exudation.  In  the  first  two  instances  the  rhonchi  are  heard  best  over 
the  upper  anterior  part  of  the  chest,  and  between  the  shoulder-blade- : 
in  the  last,  they  are  circumscribed  to  the  region  of  the  inward- 
projected  bronchial  wall.  More  rarely,  the  sonorous  rale  occurs  in 
connection  with  pulmonary  tuberculosis,  where  the  tenacious  muco- 
pus  may  partially  plug  a  large  bronchus. 

The  sibilant  rhonchus  has  a  characteristic  high-pitched,  whistling, 
hissing,  squeaking,  or  shrill  piping  sound,  also  decidedly  musical, 
heard  pretty  much  all  over  the  chest,  and  originating  in  the  smaller 
bronchial  tubes  and  bronchioles.  In  the  medium-sized  tubes  the  rales 
may  partake  of  a  sort  of  cooing  quality.  The  intensity  is  usually 
less  than  that  of  the  sonorous  rale,  but  is  quite  variable.  Where  there 
is  considerable  thickness  of  exudate  coating  the  mucous  lining  of  a 
middle-sized  bronchial  tube,  it  practically  converts  it  into  a  small- 
calibered  tube,  with  the  production  of  true  high-pitched  sibilant  rale. 
Musical  whistling  tones  may  be  caused  by  tense  threads  of  ropy  mucus 


AUSCULTATION 


171 


stretched  across  the  bronchial  lumen,  and  set  into  vibration  by  the 
respiratory  currents  of  air  like  the  strings  of  an  Eolian  harp. 

Sibilant  rales  may  be  caused  by  tough,  scanty  secretion  in  the 
fine  tubes  in  capillary  bronchitis  or  bronchopneumonitis  before  liquid 
mucus  or  muco-pus  has  begun  to  form,  or  by  the  spasmodic  muscular 
constriction  of  the  bronchioles  in  asthma,  in  which  the  characteristic 
wheezing,  whistling,  and  squeaking  noises  are  produced.  They  are 
heard  also  in  the  chronic  bronchitis  of  emphysema. 

RilES 
Moist         PO       j)ry 


Small  Moist  \~~ 
Rales 


Sibilant 
:/. Rales 


Medium  Moist--^ 
Rales 

Large  Moist 
Rales 

(Edema\ 


FIG.  41. — DIAGRAMMATIC  ILLUSTRATION  OF  DRY  AND  MOIST  RALES.     (LeFevre.) 


(2)  MOIST  OR  BUBBLING  RALES. — As  the  qualifying  names  indi- 
cate, these  rales  have  a  quality  of  soft,  bubble-forming  or  -bursting, 
arising  principally  from  the  presence  of  more  or  less  fluid  exudate  in 
the  bronchial  tubes.  Moist  rales  are  divided  into  large,  medium,  and 
small,  according  to  the  apparent  size  of  the  bubbles,  or  of  the  bron- 
chial or  pulmonary  cavities  in  which  they  are  produced.  Their  in- 
tensity is  variable,  the  larger  the  bubblings  the  louder,  with  equal 
force  of  breathing.  The  pitch,  also,  varies  according  to  the  size  of 
the  rales,  and  somewhat  upon  the  degree  of  fluidity  of  the  disturbed 
substance;  those  produced  in  the  main  bronchi,  for  example,  by  the 
vibrations  of  thin,  watery  mucus,  serum,  blood,  or  pus  are  decidedly 
lower  in  pitch  than  those  set  up  in  the  medium-  or  small-sized  tubes 
by  the  movements  of  air  through  a  thicker,  stickier  liquid. 


172  PHYSICAL    DIAGNOSIS 

Gurgles  or  gurgling  rales  are  the  loudest,  lowest-pitched  rales 
usually  met  with.  They  may  be  tracheal  or  cavernous  in  their  seat 
of  origin.  The  tracheal  rales  are  the  coarse  hubbies  which  occur  in 
connection  with  many  terminal  conditions,  where  the  rapidly  failing 
powers  and  comatose  state  allow  usually  the  seromucous  liquid  from 
the  filling,  edematous  lungs  to  gradually  creep  up  to  the  tracheal  level, 
thus  constituting  the  so-called  "death-rattle,"  although  death  does 
not  always  and  necessarily  ensue  when  these  large  tracheal  gurgles  are 
heard.  They  are  distinctly  audible  without  the  aid  of  a  stethoscope, 
and  often  at  a  distance  of  several  yards  from  the  patient. 

Very  diagnostic,  however,  are  the  large  liquid  gurgles  of  hollow, 
metallic  quality  heard  over  phthisical  cavities  of  the  lung,  where  there 
is  a  considerable  amount  of  fluid,  and  especially  when  communicating 
with  a  bronchus  dipping  below  the  level  of  the  latter.  Gurgling 
rales  are  heard  about  equally  well  during  inspiration  and  expiration, 
and  are  also  excited  readily  by  coughing.  The  presence  of  a  large 
bubbling  or  cavernous  rale  at  either  apex  cannot  arise  from  the  bron- 
chial tubes  within,  as  they  are  too  small,  but  must  mean  a  large 
pathologic  space — a  cavity,  especially  if  the  rale  seems  close  to  the 
auscultating  ear.  Elsewhere,  large  or  medium  moist  rales  may  indi- 
cate also  bronchial  dilation,  and  have  a  more  distant  quality. 

Cavernous  gurgles  may  be  absent,  constantly  or  temporarily,  be- 
cause of  the  following  conditions:  The  cavity  may  be  empty  of  liquid; 
it  may  be  entirely  rilled  with  liquid,  excluding  the  air;  the  level  of 
the  liquid  may  be  below  the  opening  of  the  bronchial  tube;  the  latter 
may  be  obstructed,  as  by  a  plug  of  inspissated  muco-pus;  rarely,  the 
cavity  may  be  partially  or  completely  occluded  by  the  pressure  of  a 
pleuritic  effusion. 

Large  mucous  rales,  of  a  loud,  low-pitched,  bubbling  character — 
though  lacking  the  .hollow,  deep  sound  of  the  cavernous  rale — when 
heard  over  the  position  of  the  main  bronchi,  are  significant  of  the 
stage  of  free  liquid  secretion  of  acute  or  chronic  bronchitis.  Simi- 
larly, slightly  higher-pitched,  medium-sized  moist  rales,  heard  lower 
down  and  in  the  interscapular  region,  over  tubes  of  moderate  caliber, 
indicate  the  presence  of  a  deeper-seated  bronchitis  with  mucoserous 
or  purulent  fluid,  or  of  a  hemorrhage  into  the  tubes,  or,  possibly,  of 
pulmonary  edema,  the  transuded  liquid  having  risen  to  the  level 
of  the  tubes. 

The  fine  moist  or  subcrepitant  rale  is  the  smallest  of  the  rales 
having  a  moist  quality.  It  is  produced  in  the  finest  tubes  or  bron- 
chioles. Its  character  is  that  of  the  bursting  of  the  tiniest  bubbles, 


AUSCULTATION  173 

or,  more  often,  the  separation  of  the  moist,  sticky  walls  at  the  time 
of  the  respiratory  passage  of  air-currents.  This  rale  is  so  fine  and 
high-pitched  that  it  approaches  the  dry,  crackling  quality  of  the 
crepitant  rale  (vide):,  hence  the  term,  subcrepitant.  While,  as  just 
intimated,  this  fine  moist  rale  may  arise  from  the  air-disturbed  liquid 
secretion  in  the  bronchioles  or  air-cells,  the  more  probable  explana- 
tion is  that  it  depends  upon  the  rapid  and  sharp  "  separation  of  the 
agglutinated  walls  of  these  finer  air-passages  from  each  other  "  rather 
than  upon  the  formation  and  bursting  of  bubbles.  The  force  of  res- 
piration is  so  slight,  and  the  caliber  of  the  tubes  is  so  small,  as  to  be 
insufficient  for  the  raising  of  bubbles.  Because  of  the  greater  force 
of  inspiration,  therefore,  the  subcrepitant  rale  is  usually  more  evident 
during,  or  rather  near,  the  end  of  the  inspiratory  breath  sound,  but 
also  with  the  expiratory  sound  if  the  exudate  in  the  bronchioles  is 
not  too  tenacious.  A  sound  similar  to  the  finest  moist  rale,  as  pro- 
duced in  the  terminal  bronchial  tubes  and  vesicles,  may  be  obtained 
by  pulling  apart  the  thumb  and  finger  or  palms  of  the  hands,  which 
have  previously  been  wetted  with  a  sirupy  or  gummy  liquid. 

The  conditions  causing  the  subcrepitant  rale  are  numerous.  They 
may  be  local  or  more  or  less  general.  When  present  only  in  one 
apex,  a  number  of  these  small,  moist,  crackling  rales  indicate  be- 
ginning tuberculous  bronchopneumonia — phthisis,  indeed,  as  a  single 
"  click  "  heard  over  an  apex  is  almost  diagnostic  of  incipient  tuber- 
culosis; but  they  may  be  heard  also  during  the  second  stage  of  the 
disease,  while  cheesy  degeneration  and  liquefaction  of  the  tuberculous 
deposit  is  going  on. 

They  may  be  detected  around  the  borders  of  pneumonitic  consoli- 
dation from  various  causes,  on  account  of  the  adjacent  collateral 
edema  or  congestion,  or  bronchial  catarrh.  As  accompaniments  of 
the  so-called  lobtilar,  catarrhal,  or  bronchopneumonitis  of  the  very 
old,  and  of  young  children,  they  are  characteristic;  here  they  are 
due  to  the  capillary  bronchitis  in  the  second,  or  moist,  stage,  the 
subcrepitant  rales  following  the  sibilant  rhonchi  of  the  first,  or  dry, 
stage.  In  this  disease  the  rales  occur  over  multiple  small  areas  pos- 
teriorly, or,  in  extensive  cases  of  bronchiolitis,  may  be  heard  all  over 
the  chest. 

As  the  so-called  rale  redux,  the  subcrepitant  rale  is  commonly 
present  in  the  later  or  resolving  stage  of  lobar  pneumonitis. 

The  discovery  of  fine  moist  rales  in  the  infrascapular  regions 
may  point  to  pulmonary  edema,  hypostatic  congestion,  or  an  effusion 
of  blood  into  the  bronchial  tubes. 


174  PHYSICAL   DIAGNOSIS 

Variations  and  conditions  modifying  the  bronchial  rales  are  im- 
portant for  consideration  before  taking  up  the  crepitant  rale,  which, 
when  not  pleuritic  in  origin,  is  produced  abnormally  within  the 
alveoli. 

Besides  the  variations  in  quality  and  pitch  already  given,  the 
size,  loudness,  and  location  of  the  rales,  their  bronchial  origin  is 
characterized  by  the  facts  that  they  are  most  changeable  as  to  audi- 
bility or  intensity  in  any  particular  locality;  also  as  to  number  and 
the  effects  of  cough.  The  additional  significance  that  the  bronchial 
rales  accompany  both  inspiratory  and  expiratory  breath  sounds,  and 
that  their  tone  or  character  is  influenced  by  the  condition  of  the 
surrounding  lung,  must  also  be  noted. 

Further  details  of  importance  in  diagnosis  are  appropriately  con- 
sidered, therefore,  at  this  juncture. 

In  the  first  place,  rales  vary  greatly  in  character.  This,  as  pre- 
viously intimated,  is  a  feature  of  the  bronchial  rales,  and  reference 
to  it  bears  repetition  here  in  a  more  specific  way.  During  and  after 
an  asthmatic  paroxysm,  for  instance,  a  multitude  of  all  sorts  of 
rales  may  be  heard  within  a  few  hours.  In  a  case  of  bronchitis, 
dry  rales  are  commonly  followed  by  moist  rales.  At  one  time  the 
rales  may  be  large  and  bubbling,  and  shortly  afterward  these  may 
be  replaced  by  small  moist  rales  as  the  pathologic  condition  extends 
downward. 

Secondly,  bronchial  rales  in  particular  exhibit  differences  in  in- 
tensity. Their  loudness,  however,  does  not  depend  upon  their  num- 
ber, but  upon  the  force  of  the  breathing.  The  value  of  the  attribute 
of  loudness  rests  upon  the  localization  of  the  rales  with  more  pre- 
cision; the  louder  a  rale  becomes  in  moving  the  ear  over  the  chest 
the  nearer  one  approaches  the  spot  of  its  generation.  This  involves 
the  question  of  the  transmission  of  rales.  It  should  be  remembered 
that  the  region  where  a  rale  is  heard  at  once  does  not  necessarily 
correspond  to  the  part  of  its  origin.  It  is  rare,  however,  to  find 
rales  transmitted  from  one  lung  to  the  other;  that  is,  if  rales  are 
audible  over  both  sides  of  the  chest,  it  may  be  inferred  that  the 
cause  exists  bilaterally,  as  in  bronchial  asthma.  Usually  the  dry 
rales  are  conducted  to  a  greater  distance  than  even  the  loudest  of 
the  bubbling  sounds.  When  the  adjacent  lung  tissue  is  thickened 
from  any  cause,  increasing  its  conducting  power,  the  rales  produced 
beneath  are  heard  with  exaggerated  intensity.  In  cases  having  very 
loud,  especially  sonorous  rhonchi,  and  where  the  thoracic  walls  are 
comparatively  thin  and  elastic,  their  vibrations  are  transmitted  to 


AUSCULTATION  175 

the  surface  so  as  to  be  palpable — rhonchal  fremitus  (see  under  Pal- 
pation). 

Thirdly,  the  irregularity  and  inconstancy  of  the  bronchial  rales 
is  very  characteristic.  This  applies  especially  to  their  evidence  and 
recurrence,  as  influenced  by  coughing  and  breathing.  Thus  they  vary 
as  to  location.  Before  one  may  be  assured  that  there  are  no  rales 
present  in  a  patient,  it  is  always  well  to  have  him  cough,  and  then 
take  a  full  breath  a  few  times.  Both  dry  or  musical  and  moist  or 
bubbling  rales  may  be  developed  or  increased,  diminished  or  removed 
at  a  given  spot  by  cough  or  forced  respiration.  They  may  occur  at 
several  different  places  within  a  short  time,  in  the  most  transient, 
fugitive  manner;  appearing  where  before  they  were  absent,  disappear- 
ing where  they  were  present,  shifting  from  place  to  place  from  day  to 
day,  or  even  while  the  patient  is  under  examination. 

Fourthly,  the  stage  of  respiration  in  which  the  rales  occur  is  quite 
significant  in  most  cases.  Bronchial  rales,  dry  and  moist,  may  be 
heard  during  both  inspiration  and  expiration,  or  either  alone.  The 
sibilant  rhonchi  are  more  frequently  audible  toward  the  end  of  in- 
spiration, except  in  asthma  and  emphysema,  where  the  expiratory 
difficulty  causes  exaggeration  of  the  force  of  that  act  by  the  auxiliary 
muscles  of  respiration.  The  sonorous  rhonchi  may  be  heard  through- 
out the  whole  of  inspiration  and  expiration,  provided  the  latter  is 
not  unduly  weakened.  The  large  moist  rales  are  also  nearly  con- 
tinuous, especially  in  diffuse  bronchitis  with  copious  liquid  secretion. 
If  scanty,  the  bubbling  sounds  may  be  limited  to  the  inspiratory 
portion  of  the  breathing.  Sometimes  the  rales  occupy  the  whole 
of  the  respiratory  act  so  completely  and  loudly  that  the  breath  sounds 
may  be  entirely  obscured.  The  subcrepitant  rale  is  not,  as  a  rule, 
evolved  with  a  promptness  simultaneous  with  the  beginning  of  in- 
spiration, but  is  apt  to  occur  with  variable  suddenness  at  the  end 
of  inspiration  or  the  beginning  of  expiration.  The  rales  are  few  in 
number,  and  often  dissimilar  to  each  other.  They  are  influenced 
by  coughing,  and  manifest  the  changeableness  of  other  bronchial 
rales. 

Fifthly,  bronchial  rales  may  be  modified  in  quality  according  to 
the  condition  of  the  adjacent  lung.  They  may  have  a  resonant  or 
ringing,  even  metallic  character.  Thus  the  dry,  humming,  purring, 
sonorous  rales  may  change  from  a  toneless  noise  to  a  clear,  resonant, 
almost  musical  sound.  This  happens  in  certain  cases  of  bronchitis 
with  tough  mucus  accompanied  with  thickening  of  the  lung,  as  at  the 
beginning  of  the  second  stage  of  pneumonia.  Sibilant  rhonchi  are 


176  PHYSICAL    DIAGNOSIS 

seldom  "  consonant "  or  ringing,  owing  to  the  damping  effect  of  the 
surrounding  air-filled  vesicles  in  the  cases  of  asthma  and  emphysema 
in  which  they  are  commonly  heard.  More  often  moist  rales  become 
ringing. 

Besides  consolidated  lung  tissue,  resonant  rales  arise  in  close 
proximity  to  cavities.  The  ringing  rales  bear  about  the  same  acoustic 
relation  to  the  non-ringing  that  bronchial  breathing  does  to  normal 
vesicular  breathing.  The  explanation  is  found  in  the  fact  that  dense 
tissue  transmits  the  rale  sound  with  a  favorable  intensification.  If 
the  individual  bubbles  are  few  and  of  deep-seated  origin,  their  reso- 
nant character  may  be  barely  noticeable.  Further,  it  is  not  invariably 
true  that  moist  bronchial  rales  within  the  neighborhood  of  condensed 
tissue  are  ringing  in  quality;  for  the  area  of  thickening  may  be 
small,  or  there  may  still  be  patches  of  expansible,  spongy  lung  tissue 
between  those  of  the  deposits  of  thickening. 

The  clearest  ringing  moist  rales  occur  within  or  very  closely  to 
superficially  situated  cavities  of  fair  or  large  size,  and  surrounded 
by  a  zone  of  consolidated  lung  parenchyma.  Here  the  ringing  may 
assume  a  distinct  clanging  (klang),  or  metallic  tone,  thus  corre- 
sponding to  amphoric  resonance  and  breathing  as  the  ordinary  ringing 
rales  do  to  bronchial  breathing. 

While  the  resonant  rales,  then,  indicate  the  positive  presence  of 
consolidation  or  excavation  of  the  vesicular  tissue  (except  as  below), 
on  the  other  hand,  non-resonant  rales  do  not  necessarily  exclude  such 
conditions.  In  instances  of  the  latter,  the  physical  changes  are  de- 
tected by  dulness  or  tympany,  as  the  case  may  be,  and,  on  ausculta- 
tion, bronchial  or  cavernous  respiration. 

With  two  exceptions,  ringing  rales  are  practically  never  associated 
with  vesicular  breathing.  In  the  first  place,  in  the  simple  bronchitis 
of  children,  without  any  evidence  of  consolidation  or  cavity,  the  rales 
not  infrequently  have  a  resonant  character  because  of  the  marked 
elasticity  of  the  lungs  and  chest  wall.  Again,  in  certain  cases  of 
emphysema,  along  with  the  generalized  sibilant  and  snoring  rhonchi, 
there  may  be  a  circumscribed  region  over  a  lower  lobe,  without  bron- 
chial breathing  and  dull  percussion  note,  that  is,  evidence  of  con- 
densation of  lung;  or  of  tympany  and  cavernous  or  amphoric  breath- 
ing, that  is,  signs  of  cavity;  and  yet  the  presence  of  ringing  rales: 
here  we  may  infer  a  deep-seated  bronckiectatic  cavity,  or  possibly  a 
bronchopneumonic  deposit,  to  account  for  the  phenomena. 

(3)  THE  CREPITANT  RALE. — This  rale  is  distinctive  because  it  is 
the  finest  of  rale  sounds,  having  a  special  acoustic  quality  which 


AUSCULTATION  177 

permits  it  to  be  classified  as  the  finest  moist  sound  as  regards  its 
origin,  but  is  more  often  referred  to  as  a  dry  rale  because  of  its 
peculiar  quality;  the  quantity  of  moisture  is  so  small,  and  the  spaces 
within  which  the  crepitations  are  produced  are  also  so  small — namely, 
the  alveoli  and  terminal  bronchioles — that  the  sounds  consist  of  a 
number  of  fine,  dry  crackles;  hence  the  term.  The  fineness  and 
dryness  of  the  rale  may  be  imitated  by  rubbing  a  small  lock  of  hair 
between  the  finger  and  thumb  close  to  the  ear,  or  by  throwing  salt 
on  a  fire.  The  crackles  are  entirely  wanting  in  the  fine,  moist,'  al- 
most bubbling  quality  of  the  subcrepitant  rale.  Other  points  of  dif- 
ferentiation between  these  somewhat  similar  adventitious  sounds  are 
as  follows:  (a)  The  crepitant  rales  are  more  numerous  than  the  sub- 
crepitant, the  minute  crackles  succeeding  each  other  so  rapidly  that 
to  the  tyro's  ear  they  may  seem  like  a  continuous  sound — like  the 
very  distant,  hardly  audible  explosion  of  a  bunch  of  firecrackers; 
(b)  crepitations  are  uniform  or  equal  in  size,  while  the  subcrepitant 
rales  are  variable  in  size;  (c)  the  crepitant  rales  are  not  influenced 
by  coughing,  as  are  the  subcrepitant,  being  heard  equally  well,  if  not 
better,  after  as  before  the  cough,  probably  because  of  the  temporary 
increase  in  the  fulness  of  the  inspirations. 

Until  recently  it  was  taught  that  the  crepitant  rale  occurred  in- 
variably and  pathognomonically  at  the  time  of  inspiration,  and  usually 
at  the  end  of  inspiration.  While  this  is  true  in  the  majority  of  cases 
in  which  the  crepitant  rale  is  met  with,  nevertheless  it  is  often  heard 
at  the  beginning  of  expiration,  and,  at  any  rate,  the  precise  time  at 
which  it  is  heard  depends  upon  the  pathologic  condition  causing  it. 
Thus,  it  is  generally  spoken  of  as  the  characteristic  rale  of  the  first 
or  congestive  stage  of  acute  lobar  pneumonia,  in  which  it  is  held 
that  the  pulmonary  capillaries  of  the  affected  lobe,  soggy  with  an 
excess  of  blood,  permit  an  incipient  transudation  of  some  of  the 
latter's  serum,  causing  an  agglutination  of  the  intravesicular  walls 
with  the  expiratory  contact,  the  separation  of  which  with  the  suc- 
ceeding inspiration,  however,  giving  rise  to  a  number  of  fine  crepi- 
tations corresponding  to  the  number  of  vesicles  (or  terminal  bron- 
chioles) in  which  the  sticky  contact  is  overcome.  This  explanation 
makes  the  crepitant  rale  exclusively  intrapulmonary  in  origin. 

On  the  contrary,  the  extrapulmonary  or  pleuritic  causation  of  the 
rale  has  its  advocates  also.  That  is,  it  is  maintained  that  it  is  nothing 
more  than  the  finest  kind  of  pleuritic  friction  sound.  For  it  is  a 
well-known  fact  that  the  pleural  covering  of  that  portion  of  the 

lung  affected  by  the  pneumonitic  process  is  practically  always  in- 
14 


178  PHYSICAL    DIAGNOSIS 

llanicd  simultaneously,  and  really  produces  the  "stitch  in  the  side" 
which  is  complained  of  by  pneumonia  patients.  Undoubtedly,  the 
brief  contact  of  the  viscid  pulmonary  and  costal  pleural  surfaces  at 
the  end  of  inspiration,  and  their  separation  or  slight  friction  at  the 
beginning  of  expiration,  are  frequent  contributory  causes  in  the  pro- 
duction of  the  crepitant  rales.  In  a  certain  number  of  cases  I  have 
been  led  to  infer  that  the  regular,  persistent  occurrence  of  crepita- 
tions at  the  end  of  inspiration  only,  disappearing  with  the  positive 
establishment  of  consolidation  twenty-four  hours  later,  pointed  to 
their  intrapulmonary  origin.  Again,  their  coincidence  with  the  be- 
ginning of  expiration,  as  accurately  determined,  and  their  continu- 
ance when  the  vesicles  were  doubtless  filled  firmly  with  fibrinous 
exudate,  along  with  the  impression  of  being  produced  near  the  sur- 
face, was  equally  significant  of  pleuritic  causation.  So  that,  as  usually 
transpires,  the  truth  embraces  both  views,  as  to  credibility  and  proba- 
bility. A  third  explanation,  that  crepitant  rales  are  "  caused  by  the 
bursting  of  fine  bubbles  formed  by  the  forcing  out  during  inspiration 
of  the  secretions  from  the  bronchioles  into  their  infundibuli,"  is 
more  consistent  with  the  development  of  patches  of  bronchopneu- 
monitis  than  of  lobar  pneumonia.  Pleural  crepitations  may  be  diag- 
nosticated sometimes  by  eliciting  a  greater  abundance  of  them,  with 
increased  loudness,  by  the  pressure  of  the  stethoscope  with  persist- 
ence after  coughing. 

The  crepitant  rale  is  sometimes  heard  accompanying  the  sub- 
crepitant  in  the  final  stages  of  resolution  in  pneumonia  (crepitans 
redux).  It  is  present,  also,  in  connection  with  cases  of  tuberculosis 
(apices),  catarrhal  or  bronchopneumonitis  (bases),  infarctions,  ate- 
lectasis,  and  edema  of  the  lungs,  although  more  rarely  than  the  finest 
bubbling  or  subcrepitant  rale. 

Atelectatic  crepitations  deserve  brief  separate  consideration.  They 
may  be  intimately  connected  with  pathologic  pulmonary  conditions, 
or  only  remotely  so,  as  on  the  border-line  of  the  normal.  As  regards 
the  former,  they  may  occur  over  lung  that  is  partially  compressed  by 
a  pleural  effusion,  and  the  patient  is  induced  to  take  deep  inspirations 
while  one  listens ;  or  over  collapsed  lung,  similarly,  when  either  main 
bronchus  is  compressed — by  a  large  aneurism,  for  example — or  oc- 
cluded within  by  a  foreign  body.  Patches  of  atelectasis  between  areas 
of  bronchopneumonia  posteriorly  may  be  manifested  by  scattered 
crepitations,  when  other  physical  signs  are  absent  or  elicited  dubi- 
ously, on  account  of  the  smallness  of  the  areas.  Here  one  must, 
furthermore,  be  guarded  against  mistaking  the  subcrepitant  rale  which 


AUSCULTATION  179 

accompanies  the  bronchiolitic  catarrh  for  the  finer,  drier,  higher- 
pitched  crepitant  rale. 

Again,  almost  physiologic  are  the  crepitations  heard  at  the  end 
of  a  deep  inspiratory  effort  in  those  who  are  congenitally,  habitually, 
or  because  weak,  sickly,  or  invalided  from  other  diseases,  poor  breath- 
ers. Those,  particularly,  who  are  predisposed  to  "  consumption " 
seldom  inflate  the  apices  of  their  lungs  with  ordinary  respiration,  and 
do  so  with  difficulty,  even  by  forcible  breathing,  as  they  may  be 
able.  Patients  who  are  obliged  to  remain  in  bed  because  of  pro- 
tracted, exhausting  illness,  not  infrequently  give  evidence  of  vesicu- 
lar collapse  by  the  inspiratory  crepitations  heard  with  increased 
respiratory  efforts;  these  are  usually  found  at  the  base  of  the  lungs, 
at  their  borders,  laterally  and  posteriorly.  In  fact,  in  many  persons 
of  ordinary  health,  but  whose  respiratory  function  is  superficial  and 
sluggish,  as  in  those  with  sedentary  habits,  or  who,  in  standing  or 
sitting,  habitually  assume  faulty,  confined,  stooping,  round-shouldered 
attitudes,  fine  crepitant  rales  are  often  heard  along  with  the  full 
breathing  needed  to  overcome  the  atelectasis.  We  discover  them  over 
the  apices  of  the  young — students,  clerks,  factory  and  shop  hands, 
etc.;  quite  commonly  at  the  bases,  especially  in  the  lower  axillary 
regions,  of  individuals  over  forty  or  forty-five  years  of  age — as  in 
professional  and  business  and  club  men,  government  officials,  and  so 
on,  who  sit  and  ride  too  much,  and  walk  or  exercise  otherwise  too 
little  out-of-doors.  Such  crepitations  usually  disappear  after  four 
or  five  full  breaths  have  been  taken. 

Laryngeal  crepitation,  as  a  sign  of  tuberculosis  (Cybulski:  con- 
firmed by  Remouchamps,  La  Semaine  medicale,  No.  48,  p.  392,  De- 
cember 2,  1903),  I  can  also  testify  to  as  of  distinct  confirmatory 
value  when  present,  although  its  absence  does  not  preclude  the  possi- 
bility of  the  disease  being  present,  nevertheless.  It  may,  however,  in 
occasional  cases  of  incipient  tuberculosis,  serve  to  determine  the  diag- 
nosis when  other  auscultatory  phenomena  fail  to  give  positive  results. 

The  method  is  simply  to  have  the  patient  preferably  lying,  with  the 
mouth  slightly  open,  while  the  physician  listens  with  the  ear  at  a  dis- 
tance of  from  5  to  10  cm.  from  the  patient's  mouth.  If  the  individual 
is  affected  with  pulmonary  tuberculosis,  a  fine  crepitation  is  heard  in 
many  cases  which  is  termed  laryngeal,  because  its  maximum  intensity 
is  near  the  larynx.  The  sound  resembles  the  scratching  of  a  pen 
moved  softly  over  paper.  It  is  heard  both  during  inspiration  and 
expiration,  but,  in  my  experience,  is  usually  more  marked  during  the 
latter.  This  laryngeal  crepitation  persists  during  the  whole  course 


180  1'IIYSICAL    DIAGNOSIS 

of  the  disease,  and  this  persistence,  together  with  its  increase  or 
diminution  along  with  the  aggravation  or  amelioration  of  the  malady, 
and  the  absence  of  the  sonorous  and  sibilant,  or  mucous  rales  noted 
in  bronchitis,  constitute  the  chief  points  in  establishing  the  diagnosis. 

The  auscultator  must  guard  against  being  deceived  by  artificial 
crepitation.  This  sound  is  produced,  so  loudly  at  times  as  to  inter- 
fere seriously  with  the  perception  of  the  respiratory  sounds,  by  the 
rubbing  of  hairs  on  the  chest  against  the  end  of  the  stethosi  •«,]»(•. 
This  source  of  error,  as  pointed  out  before  (see  Method),  may  lie 
eliminated  by  simply  wetting  or  oiling  the  hair  until  its  crispness 
is  overcome,  and  it  lies  flatly  and  closely  to  the  skin. 

The  "  mucous  click "  is  a  fine,  soft,  moist  crackle  or  "  click," 
usually  occurring  singly,  and  not  removed  by  coughing  (Loomis) ; 
it  is  virtually  an  isolated  subcrepitant  rale.  The  term  having  been 
early  associated  specifically  with  the  diagnosis  of  incipient  apical 
tuberculosis,  has  persisted  hitherto  in  clinical  language  in  the  same 
connection.  It  is  probably  due  to  the  forcible  and  sudden  inspiratory 
separation  of  the  walls  of  a  small  bronchus  which  have  been  adherent 
because  of  the  viscid  secretion  of  a  tuberculous  bronchitis,  or  of  the 
softening  down  of  an  adjacent  lobule  of  tuberculous  deposit. 

In  general,  it  may  be  said  that  in  the  majority  of  instances  where 
rales  are  heard  their  origin  is  bronchial ;  that  crackling  rales,  whether 
dry  or  moist,  occurring  at  the  bases  of  the  lungs,  usually  indicate 
some  bronchopulmonary  congestion  there  (pneumonitic) ;  at  the 
apices,  usually  a  tuberculous  broncholobular  inflammation  or  infiltra- 
tion. 

Pleural  Adventitious  Sounds. — PLEURITIC  FRICTION  SOUNDS. — In 
health,  the  smooth,  serous,  thin  pulmonary  and  costal  pleura}  glide 
over  each  other  during  the  respiratory  movements  without  noise. 
Any  diseased  condition  of  the  pleural  surfaces,  therefore,  which  pro- 
duces abnormal  roughness,  dryness,  or  thickness  is  usually  accompa- 
nied with  some  kind  and  degree  of  friction  or  rubbing  sound. 

The  favorite  location  of  pleuritic  friction  is  over  the  lower  zone 
of  the  chest,  laterally  and  posteriorly,  but  especially  in  the  axillary 
region,  where  the  excursion  of  lung  movement  is  greatest,  and  costo-- 
diaphragmatic  pleural  apposition  is  closest.  The  friction  sounds  may 
be  heard  over  a  large  area  at  the  base  of  the  lung,  on  one  side  only, 
as  a  rule,  as  in  ordinary  pleuritis,  or  rarely  it  may  be  localized  over 
a  small  area  at  the  apex  in  early  tuberculosis  (dry  tuberculous  pleu- 
risy). Again,  quite  commonly,  it  may  occur  in  small  patches,  one 
or  more,  in  the  axillary  and  infrascapular  regions. 


AUSCULTATION  181 

The  quality  and  intensity  of  the  pleuritic  friction  sounds  vary 
considerably  according  to  the  character,  chronicity,  and  degree  of  the 
pathologic  changes.  When  the  sounds  have  a  rough  rubbing,  grazing, 
shuffling,  grating,  rasping,  or  even  creaking  or  "  leathery  "  character, 
the  pleural  surfaces  are  manifestly  dry  and  roughened  by  a  fibrinous, 
cohesive  exudate  (pleuritis  sicca).  At  the  onset  of  a  pleuritis,  when 
the  only  change  is  the  early  dryness  of  the  congestion  of  the  mem- 
brane, the  friction  sound  is  hardly  more  than  a  slight,  single,  abrupt, 
grazing  or  soft  scratching  noise,  audible  over  a  variable,  but  usually 
limited,  extent  of  surface.  Moderately  and  extremely  loud  rubbing, 
grating,  or  scraping  sounds  point  to  increased  intensity  of  pleural 
inflammation  and  quantity  of  plastic  exudation  upon  the  apposed 
surfaces,  with  consequent  aggravated  attrition. 

As  suggested  by  Cabot,  "  the  sound  of  pleural  friction  may  be 
closely  imitated  by  holding  the  thumb  and  forefinger  close  to  the 
ear,  and  rubbing  them  past  each  other  with  strong  pressure,  or  by 
pressing  the  palm  of  one  hand  over  the  ear  and  rubbing  upon  the 
back  of  this  hand  with  the  fingers  of  the  other."  Friction  sounds 
seem  very  near  to  the  ear,  and  their  superficial  character  may  be 
attested  by  noting  their  intensification  when  external  pressure  is  made 
against  the  chest  with  the  head  in  immediate  auscultation,  or  with 
the  Bowles  stethoscope.  The  loudness  of  intrapulmonary  rales  cannot 
be  affected  so.  ISTot  infrequently,  in  marked  cases  associated  with  a 
harsh  grating  sound,  the  friction  may  also  be  palpable  (fremitus), 
and  equally  sensible  to  the  patient  as  well. 

In  pitch,  the  pleuritic  friction  sounds  vary  greatly,  but,  as  a 
rule,  they  are  distinctly  higher  pitched  than  the  adjacent  respiratory 
sounds. 

The  duration  of  the  individual  frictions  depends  mostly  upon  the 
extent  and  continuity  of  the  pleuritic  sticky  exudate,  the  dilatability 
and  freedom  of  motion  of  the  lung,  and  upon  the  amount  of  pain. 
A  single  short  rub,  or  several  short,  scratchy  sounds  following  each 
other  in  rapid  succession  without  the  intervention  of  a  pause,  signifies 
one  or  more  small  patches  of  circumscribed  pleuritis,  often  bunched  to- 
gether. Again,  even  in  well-marked  cases  of  extensive  plastic  inflam- 
mation of  the  pleurae,  the  stitchlike  accompanying  pain  causes  what 
might  otherwise  be  a  friction  sound  of  long  duration,  merely  the 
shortest,  catchy,  interrupted  grazing.  Directly  connected  with  this 
element  of  duration  is  the  relation  of  friction  sounds  to  the  respiratory 
rlnjllim.  They  usually  accompany  both  inspiration  and  expiration — 
to-and-fro  sound;  frequently  they  are  heard  only  during  inspiration 


182  PHYSICAL    DIAGNOSIS 

alone,  and  only  rarely  do  they  exist  with  expiration  alone.  They  are 
louder  during  inspiration,  for  obvious  reasons,  and  are  most  audible 
at  the  end  of  this  act,  particularly  the  lighter  rubbing  sounds.  The 
loud  rasping  and  creaking  frictions  of  cases  of  pleuritic  thickening 
and  roughening  in  the  chronic  pleurites,  sometimes  with  calcareous 
infiltration  in  very  old  people,  may  be  heard  throughout  the  greater 
part  of  both  inspiration  and  expiration.  Disappearance  of  the  friction 
sounds  after  continued  deep  breathing  for  a  minute  or  two  is  ex- 
plained by  the  smoothing  out  of  the  rough  elevations  causing  the 
friction,  just  as  one  might  separate  the  buttered  surfaces  of  two 
slices  of  bread  put  together — first  by  lifting  or  pulling  them  apart, 
thus  showing  the  irregular,  wavy  appearance,  and  then,  after  pressing 
them  together  again,  remove  them  past  each  other  by  a  steady,  gliding 
motion,  thus  leaving  the  buttered  surfaces  almost  as  smooth  as  when 
spread  with  a  knife. 

For  the  purpose  of  eliciting  a  friction  sound  that  may  have  dis- 
appeared, or  when  one  is  in  doubt  as  to  the  presence  of  pleuritic 
friction  at  all,  the  arm  or  decubital  maneuvers,  as  suggested  by 
Abrams,  may  be  resorted  to.  The  first  consists  in  having  the  patient 
suspend  respiration  while  he  or  the  physician  raises  the  arm  on  the 
affected  side  over  the  head;  at  the  same  time  the  suspected  area  is 
auscultated.  This  maneuver  reverses  the  direction  of  the  movement 
of  the  parietal  against  the  pulmonary  pleura,  and  thus  may  be  the 
means  of  eliciting  a  slight  pleuritic  friction  that  may  have  disap- 
peared because  of  a  previous  smoothing  out  of  roughnesses  in  the 
ordinary  act  of  respiration.  The  decubital  maneuver  is  described  as 
follows :  "  Let  the  patient  lie  upon  the  affected  side  for  a  minute  or 
two,  then  let  him  rise  quickly  and  suspend  respiration.  Now  listen 
over  the  affected  area,  at  the  same  time  directing  the  patient  to  take 
a  deep  breath." 

The  friction  sound  is  changed  very  little,  if  at  all,  by  coughing, 
and  may  be  increased  slightly  after  that  act. 

When  a  pleuritic  friction  sound  ceases  to  be  heard,  quite  often  it 
means  that  the  surfaces  of  the  pleurae  have  become  separated  by  the 
production  of  a  liquid  effusion,  although,  on  the  other  hand,  the 
presence  of  such  an  effusion  does  not  invariably  preclude  the  audi- 
bility of  a  friction  sound  being  heard  even  over  the  seat  of  the  effu- 
sion, as  in  occasional  cases,  particularly  in  children,  the  sound  pro- 
duced above,  where  the  pleural  surfaces  are  still  in  contact,  may  be 
conducted  downward  along  the  chest  wall.  As  the  fluid  becomes 
absorbed,  or  removed  by  tapping,  in  some  cases  the  renewed  contact 


AUSCULTATION  183 

of  the  thickened  pleural  surfaces  produces  a  coarse  friction  sound 
often  louder  even  than  during  the  first  stage  of  the  pleuritis.  The 
persistence  of  this  phenomenon  may  be  sensible  to  the  patient  for 
years  after  recovery,  and  may  cause  considerable  anxiety  unless  it  is 
explained  that  pathologic  or  structural  changes  do  not  regain  the 
normal,  although  clinically  or  functionally  he  may  be  quite  well ;  just 
as  a  scar,  while  it  represents  a  healed  wound,  is  nevertheless  a  per- 
manent anatomical  alteration. 

Pleuritic  crackling  or  crepitation  consists  of  the  finest  friction 
sounds,  closely  simulating  the  crepitant  rale  of  pneumonia;  indeed, 
as  pointed  out  in  describing  that  rale,  some  clinicians  assume  its 
pleuritic  origin  exclusively.  Its  differentiation  has  been  indicated, 
and  will  be  referred  to  further,  included  as  a  pleural  sound,  in  the 
next  paragraph  but  one.  Here  should  be  mentioned  the  very  fine, 
soft,  merest  rustling  sometimes  heard  around  the  sides  and  back  of 
the  base  of  the  chest  in  acute  miliary  tuberculosis,  the  sound  being 
produced  probably  by  the  rubbing  of  the  numerous  tiny  tubercles 
studding  the  pleural  membranes,  and  projecting  slightly  above  their 
surfaces  (subpleural  friction}. 

Conditions  other  than  simple  acute  plastic  pleuritis,  or  chronic 
pleuritis,  but  which  are  revealed  in  part  by  the  friction  sounds  of 
the  accompanying  dry  pleuritis,  are  as  follows:  Consolidation  of  the 
lung  from  tuberculosis  or  pneumonitis  (already  referred  to),  pneu- 
monokoniosis,  bronchiectasis  with  reactive  pneumonia,  pyemic  de- 
posits in  the  lungs,  infarction,  and  emphysema  (Vierordt).  Friction 
sounds  of  a  distant  character  heard  at  the  base  of  the  chest,  just 
below  the  lung  borders,  are  usually  significant  of  diaphragmatic  pleu- 
ritis, a  condition  very  painful,  often  alarming  in  its  immediate  symp- 
toms, and  easily  overlooked  because  of  its  anatomic  proximity  to  such 
organs  as  the  heart,  liver,  and  stomach,  to  which  the  clinical  mani- 
festations seem  more  commonly  and  readily  referable.  Friction 
sounds  detected  at  the  base  of  the  right  lung  posteriorly,  or  in  the 
seventh,  eighth,  or  ninth  right  interspaces  anterolaterally,  may  be  due 
to  a  perihepatitis  from  hepatic  abscess  or  cancer,  or  to  a  subdia- 
phragmatic  (sub phrenic)  abscess,  and  must  be  differentiated  and 
localized  carefully,  especially  when  affected  by  the  respiratory  rhythm, 
from  those  of  true  diaphragmatic  pleurisy. 

The  principal  points  of  differentiation  between  the  pleuritic  fric- 
tion sounds  and  the  bronchial  rales  it  is  important  to  apprehend, 
as  bronchitis  is  frequently  associated  with  pleuritis.  They  may  be 
summarized  and  tabulated  as  below  (modified  after  Le  Fevre)  : 


184 


PHYSICAL    DIAGNOSIS 


Bronchial 

Not  generally  localized,  but  if 
so,  they  arc  ;i--<><-iuted  with  signs 
of  consolidation. 

Usually  bilateral,  and  varia- 
ble as  to  location,  front  or  back, 
above  or  below. 

Seldom  accompanied  by  pain. 

Various  qualities  of  dry  and 
moist  rales,  remote  from  the  aus- 
cultating ear,  and  unaffected  by 
external  pressure. 

Location,  loudness,  number, 
and  size  of  rales  variously  modi- 
fied by  cough  and  deep  respira- 
tion. 

Kale  sounds  are  very  rarely 
palpable. 


Pleura! 
Strictly  localized. 


Unilateral,  constant,  and  usu- 
ally at  the  base. 

Characteristic  pain  frequent. 

Different  qualities,  but  all 
giving  impression  of  friction  or 
rubbing,  near  to  the  ear,  and 
intensified  by  pressure  over  the 
pleuritic  area. 

Are  not  removed  or  percepti- 
bly modified  by  cough;  may  be 
temporarily  decreased  or  abol- 
ished by  forced  respiration. 

The  friction  fremitus  fre- 
quently accompanies  the  auscul- 
tated sound. 


In  certain  cases  of  diffuse  bronchial  catarrh  associated  with  pleu- 
risy, with  harshness  of  the  respiratory  murmur  and  bronchial  rales, 
the  circumscribed  friction  sounds  existing  in  the  same  part  of  the 
chest  may  be  detected  only  with  the  greatest  difficulty,  unless  they 
happen  to  be  of  the  shuffling,  creaking,  or  rumbling  character.  Ke- 
peated  auscultation,  however,  with  a  discriminating  consideration  of 
the  phenomena  just  paralleled,  will  usually  serve  to  discover  the 
association. 

Again,  the  pleuritic  element  of  a  severe  case  of  pleuropneumonia 
may  go  unnoticed,  because  of  the  greatly  restricted  movement  of  the 
consolidated  lung,  and  consequent  lack  of  audible  friction  other  than 
some  pleuritic  crepitation,  perhaps. 

PI euro pericar dial  friction  denotes  the  sound  produced  by  the  rub- 
bing of  the  inflamed,  viscid  pleural  surface  of  the  lung  surrounding 
the  heart  against  that  covering  the  pericardium.  The  rubbing  is 
generally  heard  only  during  inspiration,  and  at  the  time  of  the  car- 
diac systole;  but  if,  as  in  a  minority  of  cases,  it  is  faintly  audible 
during  expiration,  the  sound  is  intensified,  nevertheless,  during 
inspiration.  This  sound  must  not  be  confused  with  the  soft,  syn- 


AUSCULTATION  185 

chronous  cardiorespiratory  murmur  (vide)  heard  in  some  normal 
individuals. 

MKTALLIC  TINKLING. — This  term  was  used  by  Laennec  to  desig- 
nate the  silvery,  fine,  resonant  metallic  sound  of  single  bursting  bub- 
bles, or  of  falling  drops  occurring  in  pneumothoracic  or  large  pul- 
monary cavities  partly  filled  with  air  and  partly  filled  with  fluid. 
The  tinkle  has  been  likened  to  the  sound  produced  by  the  dropping 
of  water  in  a  cistern,  or  of  a  grain  of  sand  into  a  large,  hollow 
metallic  or  glass  globe.  The  intensity  is  slight,  but  distinct.  The 
pitch  of  the  tinkle  is  high,  but  one  may  perceive  occasionally  a  closely 
following  deeper  tone  of  resonance — a  sort  of  secondary,  reverberat- 
ing wave.  As  to  rhythm,  metallic  tinkling  may  coincide  with  either 
or  both  inspiration  and  expiration ;  very  often  a  single  tinkle  is  heard 
with  each  phase  of  the  breathing.  It  may  be  heard  with  quiet  respi- 
ration, or  it  may  be  developed  only  after  coughing. 

While  the  conditions  for  the  production  of  metallic  tinkle  are 
principally  those  found  in  hydro-  or  pyopneumothorax,  where  one 
hears  the  resonant  impact  of  a  drop  of  liquid  from  the  relaxed  or 
collapsed  lung,  with  its  exposed  cavity  or  bronchial  tube,  upon  the 
surface  of  the  liquid  at  the  bottom  of  the  pleural  sac,  the  contained 
air  giving  the  metallic  consonance  to  the  sound,  this  physical  sign 
may  be  associated  with  such  other  signs  of  large  phthisical  cavities, 
thin-  and  tense-walled,  as  marked  tympanitic  sound  on  percussion, 
and  amphoric  breathing.  In  some  cases  it  is  probable  that  the  tinkle 
is  the  result  of  the  bursting  of  fine,  much-inflated  moist  rales  in  the 
tissues  surrounding  a  cavity,  the  air-chamber  of  which  acts  as  a 

* 

resonator. 

Finally,  it  should  be  noted  that  a  metallic  tinkling  sound  is  some- 
tinics  heard  normally  over  the  dome  of  a  gas-  or  air-inflated  stomach 
containing  liquid,  especially  in  the  left  lower  regions  of  the  chest, 
anterolaterally. 

SUCCUSSION  OR  SPLASHING  SOUND. — That  this  may  be  heard  over 
the  stomach  is  a  common  observation,  and  that  it  may  not  be  mis- 
taken for  a  splashing  sound  produced  in  the  left  pleural  sac  needs 
but  to  be  mentioned.  Its  recognition  is  easy  when  the  conditions 
of  its  occurrence  obtain;  these  are,  the  simultaneous  presence  of  air 
and  liquid  in  the  pleural  cavity — that  is,  a  pyo-  or  liydropneumo- 
thorax.  The  splash  may  be  heard  sometimes  by  the  patient,  and 
felt  also,  when  the  body  is  given  a  sharp  shake  sidewise.  The  physi- 
cian may  shake  the  patient's  trunk  gently  himself  while  auscultating 
the  chest,  or  the  sound  may  be  heard  at  a  distance  of  several  feet 


186  PHYSICAL   DIAGNOSIS 

while  the  patient  agitates  the  fluid  by  a  bodily  jerk.  Very  rarely 
the  sign  may  be  due  to  the  existence  of  an  enormous  pulmonary 
excavation.  Rhythmic  (cardiac)  splashing  sounds  may  also  !>e 
heard  occasionally  after  certain  stab  wounds,  because  of  the  presence 
of  air  and  liquid  in  the  pericardial  sac  (pneumohydropericardium). 

The  pitch  and  intensity  (aside  from  the  effect  of  the  violence 
of  the  agitation  upon  the  latter)  of  the  succussion  sound  depend 
upon"  the  density  of  the  liquid  and  the  proportional  quantities  of 
liquid  and  air  present,  just  as  such  changes  may  be  perceived  on 
shaking  a  decanter  or  jug  partly  filled  with  air  and  fluid.  It  is 
important  to  remember  that  splashing  sounds  do  not  occur  in  ordi- 
nary pleuritic  effusion  or  hydrothorax  because  of  the  absence  of  air. 
Metallic  tinkling  may  be  an  associated  phenomenon. 

The  disappearance  of  the  succussion  splash  in  a  given  case  may 
indicate  one  of  several  things:  (a)  Thickness  and  proportional  ex- 
cess of  a  purulent  exudate — as  was  mentioned  by  Hippocrates  in  de- 
scribing this  sign  (Hippocratic  Succussion) ;  (6)  the  increase  of 
the  pleuritic  exudation  displacing  the  air;  (c)  the  encysting  and 
circumscribing  of  the  pyopneumothorax  by  the  formation  of 
adhesions. 

WATER-WHISTLING,  OR  THE  LUNG-FISTULA  SOUND. — According 
to  Unverricht,  who  first  observed  this  sign  while  puncturing  and 
aspirating  a  case  of  hydropneumothorax,  this  consists  of  a  fine 
metallic  gurgling,  bubbling,  or  splashing  sound,  heard  in  cases  of 
open  pneumothorax  where  the  opening  in  the  pleura  is  directly  be- 
low the  surface  of  the  liquid.  The  sound  may  be  simulated  some- 
what by  the  blowing  of  bubbles,  or  in  gargling  the  throat.  Its  occur- 
rence and  persistence  depend  upon  the  position  of  the  patient,  and 
the  increase  or  diminution  in  the  quantity  of  fluid. 

VEILED  PUFF. — This  is  a  short,  hollow,  puffing  or  whiffing  sound, 
sometimes  high-pitched,  occasionally  audible  over,  and  thus  diagnos- 
tic of,  small  sacculated  bronchiectatic  cavities;  it  is  heard  at  the 
ending  of  the  inspiratory  murmur. 

POST-TUSSIVE  SUCTION  SOUND.— Corwin  describes  this  as  a  "  suck- 
ing or  sometimes  semisonorous  sound,  which  has  been  heard  after 
cough,  in  case  of  cavity  with  yielding  walls  and  an  opening  into  a 
bronchus.  It  occurs  with  the  inspiratory  entrance  into  the  cavity 
of  air  which  has  been  driven  out  by  compression  in  the  act  of 
coughing." 

Indeterminate  Rales. — Besides  the  various  dry  rhonchi,  moist 
rales,  and  friction  and  other  pleural  sounds,  there  occur  at  times 


AUSCULTATIOX  187 

certain  adventitious  sounds  which,  because  of  their  indefinite,  ob- 
scure, irregular  characteristics,  must  be  classed  under  the  collective 
term,  indeterminate  rales.  Skoda  so  designated  that  group  of  me- 
dium-sized and  coarse  rales  indicative  of  the  presence  of  fluid  in  some 
of  the  larger  air-passages,  but  not  of  the  permeability  of  the  adja- 
cent or  surrounding  lung  tissue;  that  is,  these  rales,  considered  by 
themselves,  signified  a  bronchial  catarrh;  but  as  to  whether  this  was 
primary  and  simple,  or  secondary  and  complicated  by  parenchymal 
consolidation  or  excavation,  was  indeterminate. 

More  particularly,  to-day  these  indefinite  sounds  include  all 
crumpling,  fine  crackling,  soft  rumbling  sounds,  moist  or  dry,  in- 
spiratory  or  expiratory,  or  both,  which  may  be  of  doubtful  origin  or 
mode  of  production  or  conduction. 

They  are  not  necessarily  abnormal,  or  always  referable  to  the 
respiratory  organs.  On  the  contrary,  they  may  be  really  muscular 
or  integumental  sounds  in  a  healthy-lunged  individual.  For  instance, 
sounds  generated  by  the  movements  of  the  thoracic  framework  in 
deep  breathing  may  simulate  intrathoracic' rales.  In  very  old  people 
we  sometimes  hear  creaking  cartilaginous  sounds  (dryness?)  that 
may  imitate  quite  closely  the  creaking  pleuritic  friction  sound. 
Again,  as  noted  by  Walshe,  the  fine  crepitus  of  a  broken  rib  may 
be  mistaken  for  the  crepitant  rale  of  a  pneumonia.  A  moist  rhon- 
choid  sound,  or  pseudo-friction  noise,  may  also  result  from  the  pres- 
ence of  a  dropsical  serum  in  the  chest  walls.  The  imitation  may  be 
detected  by  pressing  aside  the  fluid  with  a  stethoscope;  by  its  exist- 
ing in  the  abdominal  as  well  as  the  thoracic  walls;  by  its  limitation 
to  edematous  portions,  and  the  fact  that  it  is  not  synchronous  with 
the  respiratory  movements. 

Probably  the  most  distinctive  of  the  so-called  indeterminate  rales, 
however,  are  the  crumpling  or  soft  rubbing  sounds  heard  at  the  end 
of  inspiration  in  emphysema,  especially  the  interlobular  variety.  The 
dull,  soft  crackle  has  been  likened  to  that  produced  in  bending  parch- 
ment to  and  fro. 

Crepitations  are  sometimes  heard,  variable  as  to  dryness,  large- 
ness, abundance,  and  rhythm,  over  the  sternum,  during  forced 
respiration  only.  They  may  be  physiologic,  due  to  the  sudden 
dilation  of  the  marginal  lung  vesicles  or  to  fine  mediastinal 
adhesions. 

The  muscle  sounds  arising  from  the  constrained  posture  of  the 
patient,  or  when  the  breath  is  held,  have  been  referred  to  previously 
as  imitative  of  intrathoracic  rales. 


188  PHYSICAL    DIAGNOSIS 


The  auscultation  of  the  voice  is  much  less  important  and  useful 
than  of  the  breath  and  adventitious  sounds,  and  to  many  physicians 
whose  sense  of  touch  has  been  at  all  well  trained  in  palpation,  the 
changes  in  vocal  fremitus  are  felt  with  keener  perception  and  surer 
judgment  as  to  the  underlying  physical  conditions  than  are  those 
of  the  vocal  resonance.  The  signs  of  the  latter  are  more  uncertain, 
confusing,  and  obscure,  and  yet  they  may  have  occasionally  decided 
auxiliary  clinical  signification.  There  is  much  room  for  a  more  ex- 
tended and  discriminating  study  and  analysis,  and  more  frequent 
and  patient  practise  of  this  method  of  auscultation. 

Just  as  in  the  palpation  of  the  vocal  fremitus,  so  in  the  auscul- 
tation of  the  whispered  or  spoken  voice,  for  the  purpose  of  obtaining 
information  as  to  the  condition  of  the  lungs  and  pleura?,  the  basis 
of  the  procedure  is  found  in  the  fact  that  the  glottic  vibrations  arc 
transmitted  downward  through  the  respiratory  tract  as  well  as  up- 
ward through  the  mouth,  "and  that  they  are  audibly  as  well  as  pal- 
pably conducted  through  the  chest  wall. 

Consequently,  also,  the  degrees  of  audibleness  and  character  of 
the  vocal  resonance  are  affected  similarly  to  the  vocal  fremitus  by 
the  same  physical  conditions  and  changes  precisely. 

The  same  guiding  rules  for  auscultating  the  breath  sounds  are 
applicable  here.  That  is,  in  brief,  whether  practising  immediate  or 
stethoscopic  auscultation,  the  method  of  rigidly  comparing  corre- 
sponding parts  on  both  sides  of  the  thorax  should  be  adhered  to. 
The  ear  and  stethoscope  should  not  be  applied  too  lightly,  to  avoid 
a  tremulous  character  of  the  resonance;  nor,  on  the  other  hand,  too 
heavily,  that  its  real  and  full  volume  and  distinctness  may  not  be 
artificially  diminished.  It  is  essential  to  have  the  patient  repeat 
monotonously  and  evenly  the  same  word  or  syllable,  maintain- 
ing the  same  tone,  intensity,  and  pitch  of  voice,  while  different 
regions  of  the  chest  are  being  examined,  so  as  to  insure  uniform- 
ity of  results,  as  in  the  performance  of  palpation  of  the  vocal 
fremitus. 

Normal  Voice  Sounds. — There  are  several  varieties  of  vocal  or 
whispered  resonance,  named  after  their  regions  of  production  in 
health.  Thus,  when  we  place  a  stethoscope  over  the  larynx  or  trachea 
while  the  person  speaks  or  whispers,  we  hear  the  NORMAL  LARYX- 
GOPIIONY  or  TRACHEOPHONY.  When  the  patient  utters  "  nine,  nine, 
nine"  or  "one,  one,  one,"  with  the  natural  speaking  voice,  the 


AUSCULTATION  189 

sounds  are  transmitted  to  the  ear  of  the  auscultator  with  marked 
intensity  and  concentration  of  force,  although  the  words  are  not 
perfectly  articulated.  In  persons  of  loud  and  grave  voice,  the  vibra- 
tions may  be  almost  painful  to  the  examiner's  ear.  At  the  upper 
part  of  the  sternum,  over  the  main  bronchi,  nearly  as  far  as  the  para- 
sternal  lines  in  the  infraclavicular  spaces,  and  in  the  upper  part  of 
the  interscapular  region,  especially  to  the  right  of  the  vertebral  col- 
umn, the  vocal  sound  is  less  intense  and  more  confused,  so  that  it 
is  rarely  possible  to  identify  the  articulate  words  when  the  free  ear  is 
closed.  This  is  the  NORMAL  BRONCHOPHONY.  It  corresponds  with 
the  bronchial  breath  sound,  and  wherever  bronchial  breathing  occurs 
pathologically  bronchophony  is  similarly  associated.  The  sound  does 
not  seem  to  smite  so  directly  upon  the  ear,  being  more  diffused 
because  of  its  greater  distance  from  the  glottis,  and  the  consequent 
diminution  of  intensity  from  the  interference  of  more  reflected,  re- 
verberating sound-waves.  The  transmission  of  the  laryngeal,  tracheal, 
and  bronchial  vocal  sounds  is  accompanied  by  a  fremitus  or  thrill 
perceptible  to  the  examiner's  ear,  a  sign  which  is  absent  when  the 
whispered  voice  is  listened  to. 

The  normal  laryngeal,  tracheal,  and  bronchial  whisper  (whisper 
brand  to  phony)  is  heard  with  a  regional  intensity  analogous  to  that 
of  the  spoken  voice.  The  whispered  voice  sounds  like,  as  in  fact  it  is, 
an  exaggerated  or  bronchial  expiratory  breath  sound  interrupted  by 
the  speech  consonants.  They  are  of  a  tubal,  high-pitched  character, 
minus  any  fremitus  conveyed  to  the  ear.  In  very  weak,  exhausted 
patients  it  is  sometimes  easier  to  elicit  the  whispered  voice  than  deep 
respirations. 

The  NORMAL  WHISPERED  RESONANCE  is  heard  over  the  lungs  as 
a  soft,  indistinct,  low-pitched,  whiffing  sound  corresponding  to  the 
articulations  at  the  larynx.  It  must  be  noted,  however,  that  in  very 
many  normal  chests  the  whispered  voice  is  not  heard  over  the  lung, 
except  quite  close  to  the  bronchi.  Wherever  bronchial  breathing 
occurs  pathologically,  the  extent  and  degree  of  the  underlying  phys- 
ical changes  will  be  indicated  also  in  the  degrees  of  clearness  and 
intensity  of  the  bronchial  whisper. 

NORMAL  VOCAL  RESONANCE. — Considering,  now,  the  spoken  voice 
as  heard  over  the  lungs,  the  ear,  directly  applied  to  the  chest  or 
aided  by  the  stethoscope,  detects  an  inarticulate  buzzing  or  humming 
of  slight  intensity  and  low  pitch,  occurring  in  barely  perceptible  waves 
of  slightly  greater  intensity  synchronous  with  the  beginning  of  enun- 
ciation of  the  words  uttered. 


I'M)  PHYSICAL    DIAGNOSIS 

NORMAL  VARIATIONS  OF  THE  VOCAL  AND  WHISPERED  RESONANCE. 
— Altogether  independent  of  disease,  the  quality  and  intensity  of  the 
whispered  and  spoken  voice  may  be  modified  hy  perfectly  natural 
conditions.  In  the  very  old,  for  instance,  it  is  louder  than  in  young 
children,  partly  because  of  the  louder,  graver-pitched  tones  of  the 
voice  and  partly,  no  doubt,  because  of  the  "  wasting  of  the  pulmonary 
parenchyma  and  the  thickening  and  hardening  of  the  bronchi  in  old 
age  " ;  and  is,  at  the  same  time,  somewhat  of  a  tremulous  or  bleating 
quality.  It  is  lessened  in  strength  in  women  also,  for  evident  reasons, 
and  in  them  and  in  children  is  distinct  only  over  the  upper  half  of 
the  chest. 

The  intensity  over  the  whole  chest  is  greater  in  those  who  have 
thin  than  in  those  who  have  fat  or  muscular,  thick  walls.  It  is 
stronger  in  front  than  behind,  except  in  the  interscapular  region ;  in 
the  infraclavicular  regions  than  below,  and  on  the  right  than  on  the 
left  side.  Because  of  the  last-named  fact — which  is  in  harmony  with 
the  slightly  greater  vocal  fremitus  on  the  right  side — the  significance 
of  an  exaggerated  vocal  resonance  on  that  side  has  less  definite  and 
decided  diagnostic  value  than  a  similar  change  on  the  left  side.  In- 
deed, the  same  regional  variations  of  intensity  hold  with  respect  to 
the  vocal  resonance  as  with  the  vocal  (tactile)  fremitus  and  the  breath 
sounds.  Hence  the  importance  of  avoiding  hastily  drawn  conclusions 
from  the  state  of  the  vocal  resonance  in  any  one  portion  of  the  chest ; 
on  the  contrary,  only  by  the  comparison  of  corresponding  parts  on 
the  two  sides,  after  allowing  for  natural  physical  differences,  may  wo 
expect  to  infer  safely  and  significantly  by  this  method  of  ex- 
amination. 

Vocal  Resonance  and  Whispered  Voice  in  Disease. — The  modifica- 
tions met  with  due  to  pulmonary  affections  are  essentially  those  of 
intensity.  The  latter  element  may  be  slightly  increased;  it  may  be 
moderately  or  markedly  increased  (bronchophony ,  pectoriloquy} ;  it 
may  be  decidedly  increased,  with  accompanying  alterations  of  quality 
(egophony,  amphoric  voice) ;  it  may  be  diminished  or  suppressed. 

Both  the  spoken  and  whispered  voice  are  similarly  affected  by  the 
same  pathologic  conditions,  as  is  the  palpable  fremitus,  and  may  there- 
fore be  considered  together.  Nevertheless,  at  the  beginning  it  should 
be  noted  that  alterations  of  the  whispered  voice  more  often  yield 
delicate  and  precise  results  than  do  those  of  the  loudly  spoken.1  The 

1  In  the  chronic  bronchitis  associated  with  senile  emphysema  and  fibroid 
phthisis,  I  have  found  the  whisper  to  elicit  viscid  mucous  rales  that  were  in- 
audible by  the  usual  respiratory  efforts  and  tests. 


AUSCULTATION  191 

reason  for  this  is  clear  when  we  apprehend  the  fact  that,  the  articu- 
lating voice  being  produced  in  the  mouth  in  its  passage  downward 
through  the  respiratory  tract  to  the  thoracic  walls,  it  has  to  "  pass 
through  the  glottis,  where  the  approximated  vibrating  cords  may  be 
supposed  to  offer  a  formidable  obstacle  to  the  transmission  downward 
of  the  spoken  words"  (Steell).  In  the  case  of  the  whispered  voice, 
therefore,  which  consists  merely  of  an  interrupted  (the  words),  exag- 
gerated expiratory  murmur,  there  is  no  glottic  closure  or  vibration  to 
interfere  with  its  downward  transmission  and  ready  conduction  to  the 
chest  wall  through  intensifying  areas  of  disease. 

(1)  EXAGGERATED  WHISPER  OR  VOCAL  KESONANCE. — This  differs 
from  the  normal  onhr  in  a  slight  increase  of  intensity.     It  occurs 
over  small  or  partial  consolidations  of  the  lung,  and  is  thus  a  useful 
sign  chiefly  in  the  diagnosis  of  tuberculosis,  associated  witlT  broncho- 
vesicular  breathing.     In  addition  to  the  simple  exaggeration  of  loud- 
ness,  the  voice  may  sometimes  seem  to  come  from  a  part  of  the  lung 
near  to  the  auscultator's  ear.     In  such  cases  there  may  be  an  atypical 
unchanged,  or  even  diminished,  vocal  fremitus.     This  may  be  noted 
in  certain  cases  of  pleuritis  with  moderate,  superficial  consolidation 
of  the  adjacent  lung  underneath.     The  whispered  voice  is  especially 
delicate   in   the   discovery   of   small  consolidations,  without   definite 
bronchial  respiration  or  increase  of  the  tactile  fremitus. 

(2)  BRONCHIAL  WHISPER  AND  BRONCHOPHONY. — Whenever  the 
normal  or  a  simple  exaggerated  whisper  or  vocal  resonance  is  aug- 
mented to  a  degree  that  is  heard  normally  over  the  trachea  and  pri- 
mary bronchi,  it  ^indicates,  over  the  lung,  that  consolidation  of  the 
vesicles  has  occurred  to  a  considerable  extent,  usually  as  in  pneu- 
monia.   Associated  with  it  is  bronchial  respiration  and  increased  vocal 
fremitus  on  palpation.    Bronchophony  may  be  elicited  also  over  large, 
complete  tuberculous  condensations  of  the  lung,  over  retracted  and 
compressed  lung  above  pleural  effusions,  over  cavities  surrounded  by 
solidified  tissue,  and   bronchial  dilations  with   thickened  walls,  and 
sometimes  in  marked  senile  emphysema.     The  absence  of  increased 
whispered  or  spoken  voice  in  undoubted  cases  of  lobar  pneumonitis 
in  the  second  stage  indicates  either  that  the  bronchus  leading  to  the 
consolidated  area  is  occluded  by  exudate,  or  that  a  large  pleuritic 
cxudate   (pleuropneumonia)   intervenes  to  nullify  the  increased  con- 
ductivity of  the  consolidated  area. 

The  bronchophonous  voice  and  whisper  are  respectively  and  rela- 
tively not  only  louder  and  more  concentrated,  but  manifest  a  vibrating 
or  wavy  quality  approaching  the  actual  articulation  of  the  syllables 


192  PHYSICAL    DIAGNOSIS 

or  words  used  instead  of  the  indistinct,  monotonous  humming  of  the 
normal  vesicular  sounds. 

(;5)  FKCTOUILOQUY;  WHISPER  PECTORILOQUY. — As  the  double- 
derived  term  suggests — chest  speech — we  have  here  a  degree  of  whis- 
per or  voice  intensity,  with  articulate  words  audible,  as  if  the  patient 
were  speaking  with  his  lips  directly  beneath  the  listener's  ear.  It  is 
a  pathologic  laryngophony,  or  an  exaggerated  bronchophony.  The 
whispered  pectoriloquy  is  even  more  striking  or  startling  than  the 
spoken.  The  words  should  be  uttered  slowly.  In  a  large  majority 
of  cases  the  presence  of  this  sign  points  to  a  fair-  or  large-sized 
cavity  of  the  lung,  especially  one  in  free  communication  with  a  bron- 
chus and  in  close  approximation  to  the  chest  wall.  The  area  of  pec- 
toriloquy is  sharply  defined,  as  a  rule.  The  loudly  transmitted  words 
have  a  hollow,  cavernous  quality.  However,  pectoriloquy  may  be  sig- 
nificant also  of  large,  dense  consolidations  surrounding  bronchi,  and 
thus  acting  as  unusually  good  conductors  of  sound  to  the  chest  wall. 
Here  the  pitch  of  the  whispered  or  spoken  voice  is  higher  than  over 
the  pulmonary  excavations.  Other  less  frequent  causes  of  pectorilo- 
quy are  collapsed  lung  from  pleuritic  effusion,  a  tumor  between  the 
lung  and  the  thoracic  wall,  pressing  upon  a  bronchus,  and  an  open, 
circumscribed  pneumothorax,  communicating  freely  and  directly  with 
a  large  bronchus. 

(4)  EGOPHONY. — A  sign  of  vocal  resonance,  to  which  Laennec  at- 
tached special  importance  in  his  "  Traite  de  1'Auscultation  Mediate." 
It  is  at  once  an  intensification — a  little  less  than  bronchophonous 
loudness — and  a  peculiar  change  in  the  qjjality  of  the  voice  trans- 
mission. This  has  a  distant,  nasal,  tremulous,  bleating  character — 
goat  voice.  The  locality  of  the  sign  is  limited  usually  to  the  region 
at  the  level  of  the  angle  of  the  scapula.  It  is  most  frequently  heard 
in  connection  with  moderate-sized  pleuritic  effusions,  although  not  in- 
variably so,  since,  as  originally  held  by  Laennec,  partial  adhesion  of 
the  lung  to  the  chest  wall  may  be  associated,  and  in  some  cases  there 
may  be  solidified  lung  beneath  a  thin  layer  of  fluid.  The  egophony 
is  best  heard  just  below  the  upper  border  of  percussion  dulness,  and 
often  conveys  the  impression  that  the  fundamental  tones  of  the  voice 
are  intercepted,  the  shriller,  high-pitched  overtones  remaining  near 
the  surface  as  a  sort  of  quivering  echo  of  the  others.  The  sign  is  not 
at  all  a  common  one  of  moderate  pleuritic  effusions,  nor  is  it  neces- 
sarily always  indicative  of  them,  as  it  is  claimed  to  have  been  heard 
in  connection  with  consolidations  of  the  lung  without  accompanying 
effusion.  The  nasal  twang  timbre  of  egophony  has  been  attributed 


AUSCULTATION  193 

to  the  partial  flattening  of  the  hronchi  from  compression  by  the  fluid. 
This  view  is  favored  on  account  of  the  fact  that  the  sign  is  absent 
in  small  effusions  (no  compression),  and  lasts  seldom  more  than 
from  five  to  seven  days  because  of  such  an  increase  in  the  amount 
of  liquid  as  to  obliterate  the  lumina  of  the  tubes. 

(o)  AMPHORIC  VOICE.  —  This  is  the  vocal  analog  of  the  amphoric 
breath  sound  and  amphoric  resonance  heard  over  large,  tense-walled, 
communicating  cavities  in  the  lung  or  open  pneumothorax.  The  voice 
has  a  ringing,  metallic  or  musical  tone,  of  variable  intensity  and 
pitch,  superadded  to  the  usual  hollow  character,  which  may  be  simu- 
lated by  speaking  into  an  empty  pitcher  or  jar.  In  some  cases  the 
words,  instead  of  being  loud  and  blurred,  may  be  as  articulate  as  in 
pectoriloquy. 

(6)  DIMINISHED  OR  ABSENT  VOCAL  RESONANCE.  —  The  same 
pathologic  physical  conditions  which  cause  the  palpable  vocal  fremi- 
tus  to  be  diminished  or  checked  likewise  so  affect  the  audible  vocal 
resonance.  Thus,  we  find  the  latter  of  weakened  intensity  in  ^bron- 
chitis whenever  there  is  much  secretion.  It  is  enfeebled,  also,  in 
in  acute  plastic  or  chronic^Zeim^ts.  with  thickening  of 


the  membranes;  sometimes  in  fibroid  phthisis  with  thickened  pleura: 
and,  when  occurring  persistently  all  over  one  lung,  other  causes  being 
excluded,  may  signify  obstruction  of  the  supplying  bronchus  by  an 
^  ancurismal  or  malignant  tumor.  Finally,  it  may  be  noted  during  the 
progress  of  dilating  pleural  conditions  which  sooner  or  later  totally 
suppress  the  voice  transmission. 

Absence  of  vocal  resonance  is  met  with  in  total  occlusion  of 
bronchi,  as  in  the  "  massive  pneumonia  "  ;  also  in  cases  of  ^pleural 
ejfusion  of  large  amount,  whether  of  air  (pneumothorax),  pus  (pyo- 
thorax),  serum  (hydrothorax),  or  blood  (hemothorax)  :  they  all  act 
as  insulators,  interfering  with  the  conduction  of  voice  vibrations  to 
the  chest  surface.  Very  thick,  old,  dense  pleura?  may  likewise  annul 
the  vocal  transmission. 

Baccelli's  Sign.  —  This  is  the  use  of  the  whispered  voice,  to  differ- 
entiate a  serous  from  a  purulent  pleural  effusion.  The  conditions  are 
not  always  favorable,  nor  is  the  observation,  therefore,  conclusive  or 
reliable  in  all  cases  that  the  transmitted  whispered  voice  is  charac- 
teristic of  serous,  and  the  non-transmitted  voice  of  purulent,  effusion 
(empyema).  For  example,  the  whispered  voice  may  be  totally  sup- 
pressed in  very  large  serous  exudations;  and,  on  the  other  hand,  in 
certain  cases  of  small,  recent  collections  of  pus  in  the  pleural  sac, 
the  voice  conduction  is  not  completely  abolished. 
15 


194  PHYSICAL    DIAGNOSIS 

Artificial  Vocal  Resonance;  Plegaphonia. — A  method  devised  by 
Scherwald  whenever,  for  diagnostic  and  therapeutic  reasons,  it  is  im- 
perative to  simulate  the  voice  sounds.  This  emergency  may  arise  in 
persons  who  are  constantly  dumb  (aphonic),  or  unconscious,  or  ex- 
hausted, or  whom,  as  in  pulmonary  hemorrhage  (hemoptysis),  it  is 
inadvisable  to  have  speak.  The  procedure  consists  in  practising  ham- 
mer-pleximeter  percussion  over  the  thyroid  cartilage  of  the  larynx  or 
the  upper  trachea.  The  tapping  should  be  gentle,  with  the  patient's 
mouth  closed.  While  this  is  being  done  by  an  assistant,  we  auscultate 
the  artificial  vocal  vibrations,  as  it  were,  thus  set  up,  preferably  during 
expiration.  The  sounds  produced  by  these  blows  obey  the  same  laws 
of  transmission,  exaggeration,  lessening,  and  suppression,  according 
to  the  physical  conditions  and  changes  within  the  thorax,  as  with 
the  capable,  conscious,  adaptable  phonation. 

(D)   Auscultation   of  the  Cough:  Tussive  Resonance 

Cough,  in  itself,  is  an  objective  symptom,  but  becomes  a  physical 
sign  when  auscultated  in  relation  to  the  phenomena  which  it  develops 
or  modifies  within  the  chest.  It  has  much  less  value  and  reliability, 
however,  than  the  vocal  resonance.  It  is  less  convenient  and  more 
difficult  to  observe  the  effects  of  cough  as  a  simple  matter  of  technic, 
owing  to  the  agitation  and  movements  of  the  patient's  body.  The 
latter  should  be  held  as  firmly  as  necessary  during  immediate  auscul- 
tation. The  chest  piece  of  the  stethoscope  should  also  be  watched 
carefully  during  the  act,  so  as  to  avoid  friction  and  other  extrane- 
ous sounds. 

The  character  and  intensity  of  the  cough  resonance  varies,  ceteris 
paribus,  according  to  the  same  physical  conditions  and  laws  that  the 
vocal  resonance  does. 

In  a  healthy  individual,  while  in  the  act  of  forced  coughing,  the 
laryngeal  or  tracheal  sound,  as  heard  with  the  stethoscope,  is  rather 
hollow,  and  of  a  pitch  and  intensity  varying  with  the  person's  vocal 
gravity  and  strength.  Over  the  pulmonary  regions  the  act  is  attended 
with  a  quick,  short,  dull,  indistinct,  and  diffused  sound,  without 
hollow  or  tubular  character,  or  accompanied  by  any  sensation  of 
fremitus  or  succussion  within  the  thorax.  The  external,  sudden, 
expiratory  jarring  movement  of  the  chest  is,  of  course,  quite 
obvious. 

In  disease,  the  modifications  of  the  tussive  resonance  are  termed — 
now  familiarly — dry  or  moist,  bronchial,  cavernous,  amphoric. 


AUSCULTATION  195 

The  resonance  of  the  dry  cough  is  harsh,  hacking,  or  brassy,  or 
like  a  distant  "  barking."  The  moist  sound  is  greatly  modified 
by  the  character  and  location  of  the  admixed  rales.  With  the 
stethoscope,  a  hissing  sound  is  heard  to  accompany  nearly  every 
cough. 

The  harsh,  concentrated  bronchial  cough  resonance  of  consolida- 
tion; the  hollow,  "sepulchral,"  sometimes  gurgling  of  certain  pul- 
monary cavities,  and  the  loud,  metallic,  reverberating  resonance  over 
certain  other  cavity  conditions,  all  associated  with  sensation  of  thrill 
or  freinitus  from  the  interior,  may  readily  be  understood  as  men- 
tioned. The  irritative  cough  of  pleurisy  with  moderate  effusion  may 
also  have  an  egophonic  resonance. 

Mere  mention  may  be  made  again  here  of  the  post-tussive  suction, 
or  "  india-rubber-ball  "  sound  heard  with  the  first  inspiration  after  a 
cough,  suggestive  of  cavity  with  soft,  yielding  walls,  especially  when 
accompanied  with  mucous  clicks  and  moist  rales. 

In  conclusion,  reiteration  of  the  service  of  cough  as  an  adjuvant 
to  auscultation  may  be  made.  That  is,  to  summarize,  after  repeated 
coughing  inspiration  is  deeper  and  the  respiratory  murmur  louder; 
mucous  obstruction  of  the  bronchi  is  removed,  so  that  previously 
indeterminate  breathing  becomes  more  distinct  and  definite,  vesicular 
or  bronchial,  as  the  case  may  be ;  rales  are  elicited,  intensified,  shifted, 
numerically  increased  or  diminished,  qualified. 


EXPLORATORY    PUNCTURE    OF   THE    PLEURA 
(THORACENTESIS) 

Supplementary,  and  yet  not  infrequently  necessary  and  valuable 
in  the  direct  physical  diagnosis  of  pleural  effusion,  and  its  differential 
diagnosis  from  other  conditions,  is  the  procedure  commonly  known  as 
exploratory  puncture  of  the  pleura.  Under  strict  aseptic  precautions, 
the  attached  needle  of  a  hypodermic  syringe,  or  the  small-calibered 
trocar  and  canula  of  an  aspirator,  is  plunged  vertically  into  an 
interspace — usually  the  seventh,  in  the  midaxillary  line — close  to  the 
upper  border  of  the  lower  bounding  rib,  so  as  to  avoid  the  intercostal 
vessels.  If  the  point  be  immersed  in  fluid,  the  withdrawal  of  the 
piston  or  aspirator  will  be  followed  by  an  immediate  rush  of  the 
effusion  into  the  barrel  of  the  syringe  or  into  the  aspirator  bottle. 
The  negative  value  of  a  "  dry  tap  "  depends  upon  the  length  of  the 
hypodermic  needle,  if  that  be  used,  as  in  certain  cases  of  old,  greatly 


196  PHYSICAL   DIAGNOSIS 

thickened  pleura  its  point  may  not  penetrate  to  the  liquid  within. 
Again,  the  exudate  may  be  so  thick  and  flaky  as  to  close  the  explora- 
tory needle.  Of  course,  in  acute  or  chronic  pneumonia,  merely  thick- 
ened pleura,  or  tumors  of  the  chest,  the  syringe  draws  nothing,  per- 
haps, but  a  drop  of  blood. 

When  the  differential  diagnosis  can  be  made  unmistakably  by  the 
usual  methods  of  physical  exploration,  it  may  nevertheless  be  im- 
portant to  practise  thoracentesis,  in  order  to  determine  the  nature  of 
the  liquid,  by  the  microscopic,  chemic,  and  tinctorial  and  cultural 
methods  described  in  works  on  clinical  or  laboratory  diagnosis.  Thus 
the  histologic,  chemic,  and  bacteriologic  constituents  are  ascertained. 


COMBINATION    OF   THE    PHYSICAL   SIGNS:    THEIR 
ASSOCIATED    SIGNIFICANCE 

It  must  be  evident  to  the  student  of  the  preceding  pages  that  any 
comprehensive  and  accurate  diagnosis  of  the  physical  conditions  and 
changes  of  diseased  lungs  cannot  depend  upon  the  results  of  but  one 
method  of  examination,  still  less  upon  any  single,  isolated  physical 
sign.  Eather,  one  must,  as  it  were,  "  strike  a  balance "  of  prepon- 
derating evidence  favorable  to  a  physical  diagnosis,  based  upon  a 
careful  comparison  of  all  of  the  signs  perceived  by  means  of  all  of  the 
methods  used.  This  embraces,  in  other  words,  the  searching  analysis 
of  the  relative  value  and  significance  of  the  combined  physical  signs, 
and  of  the  methods  by  which  they  are  derived,  respectively,  in  con- 
nection therewith ;  and,  further,  a  rational,  judicious  synthesis  of  these 
separate  deductions  into  a  positive  or  probable  and  harmonious  whole ; 
this  conclusion  is  the  diagnosis. 

This  intellectual  process  has  to  deal,  it  must  be  remembered  also, 
with  three  sorts  of  physical  signs  in  practically  every  case  examined, 
bearing  upon  the  statement  of  the  preceding  sentence.  These  are: 
first,  the  absolutely  clear,  definite,  unimpeachable  ones;  secondly,  those 
of  doubtful,  indefinite,  more  or  less  probable  manifestation — usually 
the  signs  of  developing  and  changing  pathologic  states;  thirdly,  the 
absent  signs — those  which  have  certain  value  as  negative  evidence 
when  the  complete  picture  for  a  diagnosis  is  wanting  in  the  apparent 
and  suggestive  signs. 

An  understanding  of  what  has  gone  before  may  be  facilitated 
by  referring  to  the  following  table,  slightly  modified  after  Da. 
Costa: 


AUSCULTATION 


197 


Association  of  Physical  Signs 


PALPATION. 

PERCUSSION. 

AUSCULTATION. 

PHYSICAL  CONDITION. 

Fremitus. 

Respiration. 

Voice. 

Unimpaired. 

Resonant. 

Vesicular 
murmur  or 
its     modifi- 
cation. 

Normal     vocal 
resonance. 

Lung  tissue  healthy 
or  nearly  so  ;  at  any 
rate,  no  increased  den- 
sity from  deposits  or 
from  pressure. 

Increased. 

Dull 

Bronchoves- 
icular      or 
bronchial. 

Bronchophony. 

Consolidation  of  lung 
structure. 

Diminished 
or  absent. 

Dull. 

Absent      or 
very  distant. 

Diminished   or 
absent. 

Pleural  effusion. 

Uncertain  ; 
mostly    di- 
minished. 

Vesiculo- 
tympanitic 
or    tympa- 
nitic. 

Feeble   or 
cavernous, 
according 
to  cause. 

Uncertain  ;  di- 
minished     or 
cavernous. 

Increased  quantity  of 
air  in  lung  or  lungs 
due  to  over-distention 
of  vesicles,  or  to  a 
cavity. 

May   be   di- 
minished. 

Amphoric  or 
metallic. 

Amphoric  or 
metallic. 

Amphoric      or 
metallic. 

Large      cavity     with 
tense,  elastic  walls. 

Uncertain. 

Cracked-pot 
sound. 

Cavernous. 

Cavernous. 

Cavity  communicating 
with  a  bronchial  tube. 

From  the  above  it  will  be  observed  that  the  signs  of  cavity  in  the 
lung  are  characteristic  in  that  the  cavernous  or  amphoric  quality  of 
sound  attends  uniformly  the  percussion  and  auscultation ;  and  it  may 
be  said,  in  addition,  that  amphoric  phenomena  accompany  the  three 
acts  of  breathing,  of  coughing,  and  of  speaking.  This  is  true  also 
of  the  adventitious  sound  known  as  metallic  tinkling. 

The  combinations  of  physical  signs  given  in  the  table  are  those 
usually  met  with  in  adults;  in  children  they  are  less  evident  and 
constant,  because  of  the  thin,  elastic  chest  walls,  principally,  the  very 
clear  lung  sound  making  it  especially  difficult  to  elicit  dulness  on 
percussion.  Again,  the  small  size  of  the  chest,  and  the  fact  that  most 
of  the  pulmonary  diseases  causing  any  dulness  are  bilateral,  make 
comparison  of  the  two  sides  less  valuable  both  by  palpation  and  per- 
cussion. Auscultation  is,  therefore,  the  method  most  suitable,  and 
to  be  applied  first,  before  the  child  is  apt  to  cry.  The  crying  voice 
may  then  be  listened  to  as  the  vocal  resonance. 

This  variability  and  uncertainty  of  the  physical  signs  is  a  marked 
feature  of  the  condition  .known  as  pulmonary  collapse  or  atelectasis, 
where  the  small  areas  of  relative  dulness  at  the  bases  of  the  lungs 


198  PHYSICAL   DIAGNOSIS 

posteriorly,  simulating  bronchopneumonia,  may  within  a  few  hours 
give  way  to  clearness,  to  be  replaced  in  the  same  regions,  or  elsewhere, 
by  impaired  resonance  again  within  a  short  time.  This  is  explained 
by  the  fact  that  in  cases  of  capillary  bronchitis,  temporary  exudative 
obstruction  frequently  causes  collapse  of  the  lobule,  the  supply  of  air 
being  cut  off  and  the  residual  air  being  soon  exhausted.  Subsequently 
the  expulsive  power  of  a  violent  expiration  may  drive  out  the  mucous 
plug,  as  during  a  paroxysm  of  coughing,  and  the  naturally  clear, 
resonant  note  is  heard  once  more.  It  is  usual  to  find  associated  with 
atelectatic  dulness  absent  respiration  or  faint,  distant  bronchovesicu- 
lar  breathing,  differing  thus  from  pneumonia  with  its  superficial, 
harsh,  bronchial  breathing.  On  inspection,  also,  labored  inspiratory 
efforts  and  recession  of  the  lower  interspaces  are  witnessed,  with  col- 
lapse of  lung  often  coming  on  suddenly. 

Finally,  it  must  be  admitted  that  the  conditions  in  certain  cases 
of  pleuritic  effusion  are  such  that  a  pneumonic  consolidation  may  be 
simulated.  In  the  absence  of  thickening  of  the  pleura,  and  with  an 
amount  of  fluid  sufficient  to  cause  considerable  compression  of  the 
lung,  the  transmission  of  bronchial  breath  sound  and  bronchophony 
may  be  quite  suggestive  of  pneumonia.  If,  however,  the  pleura  is 
thickened  by  a  simultaneous  fibrinous  deposit;  if  the  liquid  is  dense, 
as  may  be  determined  by  exploratory  puncture;  and  if  other  organs, 
as  the  heart  and  liver,  show  displacement,  pleural  effusion  is  present, 
whether  or  not  pneumonia  is  responsible  for  the  bronchial  breath  and 
voice  sounds.  The  absence  of  rales,  also,  at  least  of  consonating 
rales,  confirms  the  pleuritic  causation. 


SECTION    II 

SPECIAL    PHYSICAL    DIAGNOSIS    OF    SOME 

DISEASES  OF  THE  RESPIRATORY  TRACT, 

INDUCTIVELY  CONSIDERED 


CHAPTER   VIII 
HYPOTHETICAL  AND  RECORDED  CASES 

THE  student  having  acquired  an  elemental  and  general  knowledge 
of  the  facts  and  principles  concerned  in  the  physical  diagnosis  of 
pulmonary  and  pleural  affections,  with  their  illustrative  applications, 
he  is  now  presumably  ready  to  take  up  a  study  of  the  method  of 
arriving  at  a  complete  diagnosis  of  the  special  diseases  with  all  the 
findings  before  him.  It  is  here  deemed  more  natural  and  rational 
and  cultural  to  approach  such  study — assuming  the  general  familiar- 
ity just  referred  to — in  the  manner  that  each  one  must  necessarily 
and  responsibly  do  sooner  or  later,  at  any  rate;  that  is,  depending 
upon  his  observational  and  reasoning  powers,  learn  all  he  can,  and 
think  and  decide  as  best  he  can  about  the  physical  signs  of  each  case 
as  he  meets  with  it  in  the  hospital  dispensary  or  ward,  the  bedside 
in  the  home,  or  within  his  own  consulting  office. 

It  is  desirable  to  begin  the  habit,  as  early  as  possible,  of  inducing 
(literally,  leading  into)  a  diagnosis  by  an  analysis  of  the  collected, 
clearly  observed  physical  signs,  as  one  must  really  do  in  practise,  in- 
stead of  merely  memorizing  lists  of  physical  signs  under  the  headings 
of  the  special  diseases  in  which  they  occur  respectively,  endeavoring 
later  to  make  the  case  fit  one  of  the  lists  by  inclusion  or  exclusion — 
a  fallacy  and  too  common  procedure  to  be  unlearned  that  were  better 
anticipated  and  prevented. 

Case  No.  1. — A  young  adult,  male,  weaver  by  occupation,  working 
in  a  dusty  atmosphere,  calls  at  his  physician's  office  two  days  after 
having  been  exposed  for  several  hours  in  the  mill  to  a  draft  of  cold, 

199 


200  PHYSICAL    DIAGNOSIS 

moist  air,  in  March.  He  complains  principally  of  a  sense  of  weight, 
tightness,  or  soreness  behind  the  sternum,  a  tickling  in  the  throat  or 
below  the  suprasternal  notch,  followed  by  an  irritating,  dry,  harsh 
cough,  often  paroxysmal,  and  causing  pain  in  the  muscles  of  the 
chest,  especially  along  the  costal  margins;  the  cough  is  worse  at  night, 
on  lying  down,  and  again  in  the  morning,  on  rising ;  some  oppression 
of  breathing ;  all  of  which  points  to  an  acute  or  subacute  inflammation 
of  the  upper  respiratory  tract. 

PHYSICAL  EXAMINATION. — Inspection,  palpation,  and  percussion 
are  practically  negative,  although  at  times  a  slight  increase  in  the 
frequency  and  depth  of  the  respiratory  movements  is  visible.  On 
auscultation,  the  vesicular  respiratory  murmur  is  everywhere  normal ; 
over  both  infraclavicular  regions,  however,  near  the  sternum,  the 
bronchial  respiratory  element  is  a  trifle  harsher  than  normal,  but 
fails  to  obscure  a  few  low-pitched,  groaning  or  sonorous  rales,  and 
occasionally  a  sibilant  rale  a  little  higher  up  and  farther  out  on  the 
right  side,  these  rales  being  inconstant,  appearing  and  disappearing 
with  cough,  deep  breathing,  and  whispering.  The  vocal  resonance 
is  normal. 

ANALYSIS  OF  THE  PHYSICAL  SIGNS. — In  the  first  place,  such  a 
walking  case,  minus  the  evidences  of  severe  illness,  in  spite  of  the 
acuteness  of  the  attack  and  the  subjective  localization  of  the  discom- 
fort and  pain  to  the  region  of  the  main  bronchi,  precludes  the  proba- 
bility of  any  pulmonary  involvement  of  acute  character.  This  view 
is  quite  confirmed  by  the  absence  of  any  visible  (one-  or  two-sided), 
palpable,  or  percutory  signs  of  physical  changes  in  the  lungs — no  al- 
terations of  the  size,  shape,  symmetry,  or  respiratory  movements  of 
the  chest  suggestive  thereof,  nor,  indeed,  any  of  the  vesicular  breath- 
ing or  voice  sounds;  simply  a  roughness,  bilateral,  of  the  bronchial 
breathing  where  normally  this  type  is  heard,  indicating  an  irritative, 
congestive  swelling  of  the  mucous  membrane,  and  rales,  due  to  the 
formation  of  a  viscid  secretion  in  the  bronchi,  heard  during  inspira- 
tion and  expiration,  with  the  other  characteristics  of  purely  bronchial 
origin,  the  solitary  sibilant  rale  indicating  extension  of  the  catarrhal 
inflammation  to  a  branching  tube  of  small  size  extending  into  the 
right  apex. 

A  few  days  later  the  patient  reports  feeling  much  less  substernal 
soreness  and  oppression,  and  the  expectoration  of  a  thick,  yellowish- 
white,  slightly  frothy  sputum,  and  reexamination  elicits  but  one 
change  in  the  physical  signs — the  dry  rales  are  replaced  by  bubbling 
sounds,  of  similar  behavior. 


HYPOTHETICAL  AND  RECORDED  CASES    201 

DIAGNOSIS. — We  have  determined  a  twofold  pathologic  fact, 
namely:  (a)  inflammation  of  the  hronchial  mucous  membrane;  (I) 
its  limitation  (with  the  single  exception  on  the  right  side)  to  the 
main  bronchi,  probably  including  their  bifurcation:  a  simple  bron- 
chitis. 

Case  No.  2. — A  man,  aged  forty-four,  merchant,  during  the  preva- 
lence of  cold,  moist,  penetrating  March  weather,  is  taken  suddenly 
ill  at  midnight,  with  a  sharp  chill,  general  aching  and  depression, 
stabbing  pain  ("stitch")  on  the  right  side,  dry,  short,  restrained 
cough,  rapid  respiration  and  pulse,  and  fever.  The  pain  is  located 
in  the  axilla,  and  as  far  forward  as  the  nipple;  is  aggravated  both 
by  breathing  and  coughing.  The  patient  is  seen  by  the  physician 
for  the  first  time  nine  hours  afterward. 

PHYSICAL  EXAMINATION. — On  inspection,  the  patient  is  discovered 
lying  on  the  right  (affected)  side;  a  circumscribed,  almost  livid  flush 
on  each  cheek,  a  trifle  deeper  in  shade  on  the  right;  the  breathings 
extremely  frequent,  panting  in  character,  with  occasional  expiratory 
grunts.  There  are  no  abnormalities  of  contour  of  the  chest.  The 
respiratory  movements,  however,  are  broken,  and  restricted  somewhat 
on  the  right  side,  especially  at  the  lower  half,  and  during  the  in- 
spiratory  act.  This  is  perceived  to  affect  the  expansion  as  well  as  the 
elevation  of  the  chest.  The  movements  on  the  left  side  are  clearly 
exaggerated,  and  slightly  so  in  the  right  infraclavicular  region. 

Palpation  shows  the  vocal  fremitus  to  be  comparatively  normal, 
although,  if  anything,  but  very  slightly  diminished  over  the  right 
lower  as  compared  with  the  upper  zone. 

Percussion  on  both  sides  reveals  a  clear  note,  differing  in  the 
particular  quality  on  the  two  sides,  however.  On  the  right  side  it 
has  a  higher-pitched,  empty,  vesiculotympanitic,  almost  cracked-pot 
tone;  on  the  left,  a  lower-pitched,  rather  hyperresonant  tone. 

Auscultation  exhibits  a  weakened  respiratory  murmur  in  the  in- 
frascapular  and  axillary  regions  on  the  right  side;  over  the  upper 
lobe  it  is  a  little  harsher  than  normal ;  all  over  the  left  lung  the  qual- 
ity is  vesicular,  but  intensified,  and  at  the  same  time  notably  con- 
tinuous, while  on  the  opposite  side  (the  one  complained  of)  it  is 
interrupted  and  irregular  in  rhythm.  Quite  distinctly  heard  over 
the  right  base,  in  addition,  are  some  fine,  dry,  crepitant  rales  at  the 
end  of  inspiration.  The  vocal  resonance  is  everywhere  normal. 

Fourteen  hours  later,  at  11  P.M.,  the  distress,  pain  and  dyspnea, 
and  other  symptoms  being  aggravated,  no  change  in  the  physical 
signs  is  observed  except  a  greater  abundance  and  prominence  of  the 


202  PHYSICAL    DIAGNOSIS 

crepitant  rales,  with,  over  the  right  lung  base  also,  the  feeble  vesicular 
murmur  now  replaced  by  a  somewhat  harsh,  prolonged,  bronchovesic- 
ular  respiratory  murmur. 

The  next  (second)  day,  at  noon,  with  harassing  subjective  and 
objective  symptoms,  the  cheek  flushes  deeper  and  duskier,  orthopnea 
pronounced,  and  the  distressing  cough  accompanied  with  a  tenacious, 
sort  of  brick-red  or  rusty  sputum,  the  physical  signs  are  found  to 
be  as  follows : 

Inspection  notes  a  marked  inequality  in  the  movements  of  the 
two  sides;  that  on  the  right  is  more  restricted  than  at  first  observed, 
the  lagging  and  relative  inaction  giving  it  the  appearance  of  fulness 
and  weight,  while  on  the  left  side  the  excursion  of  movement  is,  by 
contrast,  greatly  increased.  But  the  movement  of  elevation  is  not  so 
much  diminished  as  that  of  expansion.  The  abdominal  movement 
on  the  right  side  is  likewise  visibly  obstructed. 

Palpation  now  elicits  a  positive  increased  fremitus  over  the  whole 
right  lower  lobe,  posterolaterally,  both  as  compared  with  the  up) id- 
portions  and  the  opposite  side.  Touch  confirms,  also,  the  sign-  de- 
tected ocularly. 

On  percussion,  over  the  right  side  anteriorly  a  vesiculotympanitic 
note  persists  (Skodaic  resonance) ;  posteriorly,  below  the  scapular 
angle  and  extending  into  the  lower  axillary  region,  the  sound  is  dull, 
passing  into  the  liver  dulness  to  the  borders  of  the  ribs.  On  the 
left  side,  front  and  back,  the  note  is  quite  hyperresonant ;  thus  is 
manifested  three  degrees  of  pitch  and  loudness,  as  well  as  quality, 
namely,  low-pitched,  loud  sound  on  the  left  side,  medium-pitched, 
moderately  loud  (semitympanitic)  sound  over  the  upper  part  of  the 
right  chest,  and  high-pitched,  least  loud  sound  at  the  right  base.  In 
the  latter  region  the  sensation  of  resistance  is  increased. 

Auscultation  of  the  region  of  dulness  shows  a  superficial,  loud, 
harsh,  tubular  breath  sound,  the  expiratory  sound  as  high  in  pitch  and 
as  long  in  duration  as  the  inspiratory  (bronchial  breathing).  Above, 
on  the  same  side,  the  breathing  is  simply  exaggerated  vesicular,  al- 
though, as  we  approach  the  level  of  the  seventh  rib  downward,  the 
sound  becomes  bronchovesicular.  On  the  left  side  throughout,  marked 
intensification  of  the  vesicular  murmur  is  heard.  At  the  right  base 
we  find  a  distinct  increase  of  the  loudness  of  the  vocal  and  whispered 
resonance  ( bronchophony ) . 

SYNTHETIC  ANALYSIS. — The  acute  character  and  onset,  and  loca- 
tion of  the  symptoms  point  to  an  undoubted  severe  pleural  or  pul- 
monary inflammation,  or  both,  on  the  right  side. 


HYPOTHETICAL    AND    RECORDED    CASES         203 

This  inference  is  further  confirmed  by  the  disturbed  respiratory 
movements  observed  on  the  right  side,  indicating  at  least  a  painful,  if 
not  a  mechanical,  interference  with  breathing,  rather  pleural  in  ori- 
gin with  the  predominance  of  the  former  condition ;  of  simultaneously 
combined  pulmonary  origin  with  growing  predominance  of  dyspnea, 
from  exudative  obstruction  to  the  entrance  of  air  into  the  vesicles. 

The  percutory  and  auscultatory  signs  (first  examination)  indicate 
a  relaxed  state  of  the  right  lung  (tympany)  and  compensatory  activ- 
ity of  the  left  (hyperresonance:  exaggerated  respiration).  That  this 
relaxation  of  lung  is  immediate  is  proven  by  the  fact  that  if  not  so 
the  location  of  its  determining  signs  would  be  higher  (mediate  re- 
laxation from  pleural  effusion  below,  with  visible  and  palpable  evi- 
dences of  this  below),  whereas  the  respiratory  changes  and  crepitant 
rales  heard  at  the  base  can  mean  alone  involvement  of  the  lower  lobe, 
with  some  accompanying  pleuritis  sicca,  no  doubt.  Combined,  these 
signs  point  to  the  one  acute  cause  of  such  relaxation  of  lung,  namely, 
congestion. 

This  inference  is  corroborated  at  the  second  visit  to  the  patient, 
with  the  additional  signs  of  beginning  exudation  into  the  alveoli,  and 
even  closure  of  some  lobules  already. 

Upon  scrutinizing  the  results  of  the  third  physical  examination, 
the  only  deduction  must  be  that  of  a  rapid  formation  of  complete  lobar 
consolidation,  essentially  because  of  the  localized  exaggerated  vocal 
fremitus  and  resonance,  bronchial  breathing,  and  dulness,  according 
to  the  established  acoustic  law  of  the  better  conduction  of  sound- 
waves in  full  amplitude  through  solid  than  through  air-containing 
structures. 

DIAGNOSIS. — Acute  croupous  or  lobar  pneumonitis:  The  first  stage,, 
or  stage  of  congestion,  and  the  second  stage,  or  stage  of  red  hepa- 
tization. 

With  the  patient  gravely  ill,  these  physical  signs  persist  for  seven 
days.  A  sudden  crisis  in  the  symptoms  occurs ;  the  temperature  drops 
to  subnormal,  general  prostration  is  intense,  and  cardiac  collapse  and 
a  fatal  issue  are  imminent.  The  natural  powers  of  the  system,  how- 
ever, aided  by  appropriate  and  prompt  treatment,  enable  the  patient 
to  withstand  and  survive  the  shock  and  depression.  And  still  there  is 
no  change  in  the  physical  signs — nor  in  one's  anxiety,  perhaps. 

On  the  second  day  after  the  critical  condition  just  mentioned,  the 
patient  breathing  much  easier,  the  sputum  grayish  or  yellowish,  less 
thick  and  rusty,  and  more  abundant  and  frothy,  reexamination  shows 
less  marked  exaggeration  of  respiratory  movement  on  the  left  side,  no 


204  PHYSICAL   DIAGNOSIS 

jcvkincss  on  the  right  side;  diminished  prominence  of  the  vocal  fremi- 
tus  over  the  right  base;  dulness  remains;  the  bronchial  breathing  is 
not  so  sharp,  but  more  distant,  though  quite  characteristic ;  new  rales 
have  appeared,  however,  of  a  moderately  fine,  moist  type,  heard  both 
with  inspiration  and  expiration. 

At  the  end  of  two  weeks  from  the  time  of  the  third  examination 
recorded,  very  slight  restriction  of  the  right-sided  thoracic  movement 
is  noticeable,  and  no  exaggeration  of  movement  on  the  left  side  at 
all;  vocal  fremitus  is  practically  uniform  everywhere;  a  relative  dul- 
ness over  the  affected  lobe  is  now  noted,  with  the  peculiarity  that  the 
partly  clear  element  is  tympanitic  in  quality;  hyperresonance  over 
the  right  upper  lobe  and  over  the  left  lung  has  disappeared;  broncho- 
vesicular  breathing  at  the  right  base,  here  and  there  ill-defined,  and 
coarser  moist  rales,  mingled  with  some  fine  crepitations,  are  also 
audible. 

All  of  which  points  unmistakably  to  the  transition  of  the  case 
from  the  third  stage,  or  stage  of  gray  hepatization,  to  that  of  reso- 
lution. 

That  clinical  recovery  and  pathological  recovery  are  not  synon- 
ymous, nevertheless,  is  seen  in  the  fact  that  two  months  later,  the 
patient  having  been  well  and  able  to  work  as  usual  for  nearly  (ivi; 
weeks,  the  following  physical  signs  remain:  in  the  right  infrascapular 
region  only,  slight  impairment  of  resonance,  with  sensation  of  resist- 
ance also  slightly  above  that  of  the  corresponding  left-sided  space, 
and,  besides,  a  tympanitic  character  of  clearness,  while  on  ausculta- 
tion the  breath  sounds  are  a  little  less  clear,  near,  and  loud,  yet, 
withal,  the  expiratory  portion  is  somewhat  prolonged  and  low-pitched. 

This  condition  of  affairs  is  readily  explicable  as  due  to,  in  the  first 
place,  slight  pleural  thickening  which  accompanies  practically  all  cases 
of  pneumonia,  from  extension  of  the  inflammation  to  the  surface  and 
a  lobar  pleuritis  resulting  which  leaves  the  pleura  a  trifle  less  thin, 
smooth,  and  translucent  than  normally;  hence  the  percutory  signs. 
The  fact  that  the  impaired  clearness  of  note  is  pleural  instead  of 
pulmonary  is  evident,  also,  in  the  auscultatory  indication  that  air  is 
free  to  enter  the  vesicles  over  the  same  location.  But  that  these 
vesicles  have  not  regained  their  normal  resiliency  is  equally  apparent 
in  the  persistence  of  a  tympanitic  element  and  a  prolonged  expiratory 
sound  on  percussion  and  auscultation,  respectively — significant  of  re- 
laxed lung  tissue. 

VARIATIONS. — Before  considering  the  differential  diagnosis  of 
lobar  pneumonitis,  certain  variations  of  the  physical  signs  not  met 


HYPOTHETICAL    AXD    BECOKDED    CASES          205 

with  in  the  average,  typical  case  just  narrated  should  be  pointed  out, 
because  they  enter  more  or  less  largely  into  this  question,  and  their 
recognition  and  estimation  constitute  important  items  of  resource  in 
differentiating  as  accurately  and  readily  as  possible. 

Age  is  a  factor.  When  pneumonia  attacks  a  debilitated  old  man, 
most  of  the  physical  signs  are  retarded  and  insidious  in  their  appear- 
ance and  development,  and  lack  distinctness.  This  is  particularly 
evident  as  regards  the  fremitus  and  dulness,  and,  though  less  marked, 
the  occurrence  of  bronchial  breathing,  which  may  be  distant  and  rather 
indeterminate.  In  very  young  children,  also,  a  considerable  solidifi- 
cation may  exist  without  dulness;  indeed,  there  may  be  tympany 
instead. 

Sex  and  Build. — Increased  tactile  fremitus,  which  is  an  important 
factor  in  the  diagnosis,  may  be  absent  on  account  of  the  weaker  voice 
in  women,  or  because  of  a  thick,  fat  chest  wall. 

The  location  and  extent  of  the  consolidation  may  influence  the 
physical  signs.  Thus,  in  the  more  infrequent  cases  of  apical  .pneu- 
monia, well-marked  dulness  is  rarely  met  with.  Bronchial  breathing 
is  likewise  less  obvious.  In  the  so-called  "central  pneumonia''1 — 
which,  by  the  way,  is  the  variety  most  often  met  with  in  the  aged — 
the  deep-seated  area  of  hepatization  may  escape  detection  so  far  as 
percussion  is  concerned;  and  even  on  auscultation,  the  bronchial 
breathing  may  be  so  feeble  and  distant  as  to  be  recognized  only  with 
great  difficulty  and  care.  The  pneumonitic  process  may  reach  the 
surface  later,  however,  and  then  be  more  easily  diagnosticated.  Small 
areas  may  so  be  discovered,  beginning  high  up  in  the  armpit;  in 
doubtful  cases,  therefore,  this  part  of  the  axillae  should  always  be 
examined  with  closeness.  Pneumonia  at  the  left  base  sometimes  es- 
capes early  and  definite  detection  on  account  of  the  proximity  of  an 
enlarged  stomach,  giving  rise  to  a  tympanitic  note. 

Massive  pneumonia — the  term  applied  to  that  variety  in  which 
the  bronchus  leading  to  the  consolidated  lobe  or  lobes  is  occluded  by 
exudate — may  be  particularly  puzzling  because  of  the  absent  fremitus 
and  bronchial  breathing,  and  the  more  than  usually  dull  and  resistant 
sound,  as  in  cases  of  pleural  effusion. 

"Wandering"  or  "creeping  pneumonia"  (also  migratory},  as 
the  term  signifies,  is  a  form  of  the  disease  in  which  the  signs  of 
consolidation  are  found  to  extend  from  one  lobe  to  another,  or  to 
disappear  over  one  lobe  and  appear  over  another.  This  is  more  prop- 
erly a  pneumonia  with  relapses  than  an  actual  wandering  of  the 
inflammation. 


206  PHYSICAL    DIAGNOSIS 

Again,  it  should  be  remembered  that  quite  frequently  cases  of 
pneumonia  are  first  seen  when  the  first  stage  (congestive)  has  passed; 
that  egophony  may  sometimes  be  heard  over  the  consolidated  lobe; 
that  both  dulness  and  bronchial  breathing  may  be  transmitted  a  short 
distance  beyond  the  actual  borders  of  consolidation,  especially  when, 
as  in  the  majority  of  cases  the  right  lower  lobe  is  affected,  the  en- 
larged as  well  as  solidified  lobe  is  in  close  contact  with  the  spinal 
column,  so  that  a  narrow  zone  of  moderate  bronchial  breathing  may 
be  audible  along  the  column  on  the  sound  side ;  that  the  disease  may 
run  a  short,  even  two-day  course  (abortive  form)  ;  that  it  may  also 
manifest  a  prolonged  persistence  of  the  physical  sign?,  from  (a)  de- 
layed resolution,  (b)  relapse,  or  a  modification  of  them  (c)  because 
of  a  terminal  transition  to  abscess  or  gangrene  of  the  lung. 

Finally,  while  as  a  complication  of  other  diseases  regular  pneu- 
monia may  be  seemingly  present  symptomatically,  the  physical  signs 
are  so  irregular  as  to  render  the  diagnosis  between  the  lobar  and 
catarrhal  varieties  uncertain  in  some  cases.  This  is  especially  apt  to 
occur  in  connection  with  epidemic  influenza.  A  patch  of  limited  or 
incomplete  consolidation  may  be  found  between  the  angle  of  the 
scapula  and  the  spine,  or  in  the  upper  axillary  regions,  as  indicated 
by  the  dulness  and  bronchial  breathing.  More  often,  however,  the 
physical  signs  of  the  so-called  influenzal  pneumonia  are  those  of  an 
intense  acute  pulmonary  congestion,  and  true  hepatization  does  not 
occur.  There  may  be  no  perceptible  alteration  of  the  percussion  note, 
certainly  no  dulness,  and  usually  nothing  more  than  a  general  slight 
impairment  of  resonance  over  one  lung.  Neither  is  bronchial  respira- 
tion evident;  on  the  contrary,  only  a  few  areas  of  bronchial  harshness 
(irritative)  in  the  midst  of  a  general  area  of  moderate  suppression  of 
the  breath  sounds.  Crepitant  or  some  fine  moist  rales  may  be  heard. 

The  pneumonias  which  occasionally  follow  surgical  and  accidental 
injuries  and  etherization  are  of  this  character. 

Eeference  has  been  made  to  the  fact  that  every  pneumonia  in 
which  the  inflammatory  process  extends  to  the  pleural  surface  of  the 
lobe  is  associated  with  a  certain  fibrinous  pleuritis.  But  in  some 
cases  this  latter  condition  may  become  so  severe  and  extensive  (pleuro- 
pneumonia)  as  to  give  rise  to  physical  signs  so  predominant  that  those 
of  the  pneumonia  may  be  obscured  almost  beyond  recognition.  This 
will  be  pointed  out  more  fully  below  in  differentiating  pneumonia 
from  pleurisy  with  effusion. 

DIFFERENTIAL  DIAGNOSIS. — In  the  first  stage  of  pneumonia  the 
signs  may  be  simulated  by  three  pathologic  conditions,  namely,  acute 


HYPOTHETICAL  AXD  RECORDED  CASES    207 

pulmonary  congestion  (see  under  the  preceding  heading),  liypostatic 
congestion,  and  pulmonary  edema. 

(1)  Acute  Pulmonary  Congestion. — In  the  first-named,  the  bilat- 
eral,  moderate  harshness  of  the  respiratory  murmur  soons  ends  as  it 
began,  while  in  pneumonia  the  localization  of  the  congestion  to  the 
lobe  that  is  to  be  consolidated  is  manifested  by  the  transition  within 
twenty- four  or  thirty-six  hours  of  a  rather  weakened  localized  murmur 
to  true  bronchial  breathing,  maintained  until  the  crisis,  unlike  the 
general  congestion,  the  mentioned  signs  of  which  may  be  intermittent, 
la  the  simulating  affection,  also,  the  crepitant  rale  is  much  less  con- 
stant, scanty,  generalized,  and  recurrent,  whereas  in  pneumonia  it  is 
common,  abundant,  localized,  and  recurs  only  during  resolution  (rale 
redux),  if  at  all. 

(2)  Hypostatic    Congestion. — In    the   course    of   long-continued 
fevers,  as  typhoid,  and  of  chronic  debilitating  diseases  attended  with 
weak  heart,  causing  the  patients  to  be  bedridden  in  the  dorsal  re- 
cumbent position,  such  as  cancer;  paralysis,  especially  that  following 
cerebral  apoplexy,  and  in  the  later  stages  of  diabetes,  Bright's  disease, 
and  tuberculosis,  lobar  pneumonia  may  be  suspected  as  a  complicating 
affection  when  the  simulating  signs  are  really  due  to  a  stasis  or  en- 
gorgement of   the  dependent    (postero-inferior)    parts  of  the  lungs 
from  the  combined  factors  of  a  weak,  flabby  right  heart  and  the 
influence  of  gravitation.    In  very  protracted  cases  the  congestion  may 
actually  be  transformed  into  a  liypostatic  pneumonia,  a  certain  quan- 
tity of  exudation  expelling  considerable  air  from  the  vesicles  and 
infiltrating  some  of  the  interstitial  tissue. 

Here,  apart  from  the  suggestiveness  of  the  underlying  disease, 
usually  easily  recognized,  the  physical  signs  of  a  hypostasis  may  be 
differentiated  in  the  following  particulars,  principally:  (a)  on  in- 
spection, while  the  respiratory  movements  are  somewhat  shallow  (ex- 
cept in  the  infraclavicular  regions),  there  is  not  the  painful,  one- 
sided restriction  of  movement  seen  in  true  lobar  pneumonia,  with 
exaggeration  on  the  opposite  side,  and  the  acute  dyspnea  is  absent; 
(&)  the  vocal  fremitus  is  feeble  at  the  base,  normal  above  anteriorly; 
(c)  there  is  slight  dulness  over  both  bases,  frequently  commingled 
with  a  slightly  tympanitic  quality;  (d)  on  auscultation  we  hear  the 
breath  sounds,  likewise  those  of  the  voice,  diminished.  Fine  moist 
rides  may  be  audible,  due  to  adjacent  bronchitis.  At  times  the  ex- 
piratory murmur  is  slightly  prolonged,  and  in  the  terminal  cases  of 
hypostasis,  where  some  induration  has  occurred,  the  breathing  may 
have  a  bronchial  quality.  An  important  distinguishing  point  is  the 


208  PHYSICAL    DIAGNOSIS 

fact  that  hvpostiilic  pneumonia  is  invariably  bilateral,  while  the  ordi- 
nary acute  pneumonia  is  rarely  so.  Not  infrequently  the  evidences 
of  congestion  (hypostatic)  are  a  little  more  extensive  on  the  right 
side,  the  relative  dulness  reaching  as  high,  perhaps,  as  one-third  the 
way  up  the  scapula. 

(3)  From  pulmonary  edema  acute  lobar  pneumonia  may  be  differ- 
entiated by  the  conditions  under  which  the  former  occurs  (as  a  part 
of  the  general  dropsy  of  cardiac  or  renal  disease,  and  in  the  terminal 
stages  of  chronic  anemic  and  cachectic  conditions) ;  by  the  bilateral 
impaired  resonance  arid  weak  breath  sounds  below  the  scapular  an- 
gles, and  especially  by  the  distinct  fine  moist  rales.     As  the  serous 
effusion  into  the  alveoli  increases  and  extends  to  the  higher  portion.-; 
of  the  lungs,  more  marked  dulness  and  bronchovesicular  respiration 
may  be  heard,  and  the  liquid  rales  become  less  uniform  on  account 
of  the  admixture  of  coarser  (slightly)  rales,  which  may  be  heard  also 
in  the  axillary  regions. 

As  pulmonary  edema  is  often  preceded  in  transition  by  hypostatic 
congestion,  and  may  thus  be  a  precursor  of  death  because  of  the 
greater  loss  of  strength  and  vitality  indicated,  for  prognostic  and 
therapeutic  reasons  it  is  important  to  recognize,  if  possible,  this  tran- 
sition. As  a  rule,  in  edema  the  dyspnea  is  more  marked,  and  be- 
comes rapidly  aggravated;  dulness  on  percussion  is  more  decidedly 
evident,  and  unassociated  with  a  tympanitic  quality,  and,  most  dis- 
tinctive of  all,  the  presence  of  more  or  less  fine  moist  rales. 

The  differential  diagnosis  of  the  second  or  consolidation  stage  of 
lobar  pneumonia  is  seldom  difficult,  the  only  diseases  of  importance 
simulating  it  being  pleurisy  with  effusion  (acute}  and  acute  pneu- 
monic phthisis  (tuberculosis) ;  rarely,  an  hemorrhagic  infarction  of 
the  lung  also.  The  first  of  these  will  be  considered  later. 

(4)  Acute  Tuberculopneumonic  Phthisis. — It  may  be  impossible, 
for  the  first  week  or  ten  days,  to  distinguish  this  from  ordinary  croup- 
ous  pneumonia  by  physical  signs  alone.     The  signs  of  pneumonia 
occurring  in  a  small-chested  individual  should  invariably  lead  to  a 
careful  examination  of  the  apices,  where  often  the  tuberculous  focus 
causing  the  acute  outbreak  of  extensive  consolidation  in  the  lower 
lobes  may  be  discovered.     In  acute  tuberculous  pneumonia,  again, 
evidences  of  bilateral  involvement  are  more  frequent.     Instead  of  a 
critical  decline  about  the  eighth  or  tenth  day,  the  disease  persists, 
minus  the  physical  signs  of  resolution  as  in  the  lobar  pneumonia; 
on  the  other  hand,  soon  plus  those  of  softening  and  cavity  formation, 
namely,  cavernous  or  amphoric  breathing,  gurgling  rales  and  metallic 


HYPOTHETICAL  AXD  RECORDED  CASES    209 

tinkling,  and  circumscribed  areas  of  percussion  tympany.  Otherwise, 
the  differentiation  must  be  made  by  an  examination  of  the  sputum, 
and  consideration  of  the  clinical  aspects  and  personal  and  family 
history  of  the  patient. 

(5)  In  licmorrliagic  infarction  the  signs  of  consolidation  point 
to  a  small,  circumscribed  area,  usually  in  the  middle  or  lower  lobe 
of  the  right  lung,  near  the  surface,  or  perhaps  at  one  of  the  borders. 
A  deeply  seated,  centralized  infarct,  with  the  symptoms  of  lobar  pneu- 
monia at  the  onset,  is  seldom  recognizable  by  the  methods  of  physical 
examination.  A  superficial  infarct,  however,  gives  rise  to  a  limited 
area  of  dulness  on  light  percussion;  the  fremitus  is,  if  anything, 
slightly  increased,  unless  complicated  by  pleuritis,  and  some  localized 
crepitant  rales  and  bronchovesicular  breathing  may  be  heard.  Asso- 
ciated with  these  signs  are  usually  found  those  of  valvular  heart 
disease,  especially  when  due  to  ulcerative  or  malignant  endocarditis. 
Other  septic  or  pyemic  diseases,  infectious  fevers,  and  the  puerperal 
state  and  traumatism  causing  venous  thrombosis  of  the  leg,  uterus, 
etc.,  may  be  present  as  suggestive  of  infarction  from  an  embolus 
rather  than  of  a  true  pneumonitis. 

Case  No.  3. — An  elderly  gentleman,  apparently  about  fifty-eight 
or  sixty  years  of  age,  enters  one's  office,  manifesting  some  shortness 
and  laboriousness  of  breathing,  and  embarrassed  by  brief,  harsh,  at 
times  slightly  rattling,  explosive  spells  of  coughing  attended  with  a 
scanty  mucous  expectoration.  His  lips  and  cheek  eminences  show 
some  lividity,  and  over  the  latter  the  bluishness  is  marked  by  a  net- 
work of  dilated  capillaries.  He  stands  and  walks  slightly  bowed,  and 
is  rather  bulky-chested,  although  not  large-limbed.  When  in  his  teens 
he  suffered  from  frequent  attacks  of  asthma  for  several  years,  and 
ever  since  twenty-four  or  twenty-five  years  of  age,  until  twenty  years 
ago,  worked  extremely  hard  physically  (in  iron  works).  He  has  also 
been  subject  to  more  or  less  severe  attacks  of  bronchitis,  lasting  from 
one  to  two  months,  nearly  every  winter.  He  comes  for  the  relief 
and  cure,  if  possible,  of  the  dyspnea  and  cough,  especially,  and  the 
mitigation  of  his  condition  and  of  the  recurrent  bronchitic  attacks 
generally. 

PHYSICAL  EXAMINATION. — Inspection  of  the  bared  chest  shows 
the  following:  The  peculiar  breathing  movements  of  the  thorax  at- 
tract one's  attention  at  once,  but,  confining  our  interest  to  the  size 
and  shape  of  the  thorax  first,  we  note  that  it  is  generally  enlarged 
and  rounded,  the  enlargement  being  most  marked  in  the  upper  half. 

The  whole  chest  is  higher  than  normal,  too,  and  the  neck  appears 
16 


210  PHYSICAL    DIAGNOSIS 

correspondingly  shortened  and  thick.  The  stooping  posture  is  aug- 
mented by  the  elevated  and  rounded  shoulders,  and  the  evident  in- 
crease in  the  anteroposterior  diameter,  as  well  as  by  the  exaggerated 
curve  of  the  dorsal  spine.  The  point  of  greatest  curvature  corresponds 
to  the  lower  portion  of  the  thoracic  spine.  The  sternum  is  conspicu- 
ously prominent,  arching  forward  a  little  more  noticeably  at  level  of 
insertion  of  the  fourth  rib.  The  bone  appears  unusually  broad,  how- 
ever, and  flat  at  the  angle  of  Louis — i.  e.,  the  angle  formed  by  the 
planes  of  the  manubrium  and  gladiolus  is  more  obtuse. 

The  sternomastoids  and  scaleni  antici  stand  out  prominently,  and 
the  jugular  veins  (external)  likewise,  from  distention.  Evanescent 
tumors  are  seen  rising  and  falling  above  the  clavicles  with  violent 
coughing  attacks;  at  other  times  the  supraclavicular  regions  are  de- 
pressed. The  scapulae  are  widely  separated.  The  intercostal  spaces 
are  widened,  especially  at  the  upper  part  of  the  chest.  While  the 
epigastric  angle  is  also  widened — obtuse — the  lower  portion  of  the 
chest  seems  transversely  constricted  (peripneumonic  furrow)  because 
of  the  comparatively  greater  increase  of  all  of  the  upper  diameters. 
The  heavy  ribs  are  not  uniformly  arched,  but  present  conspicuous 
angulations  at  various  points;  they  are  also  rigidly  and  horizontally 
arched  forward,  as  in  a  fixed  inspiratory  position,  especially  above  the 
sixth  rib. 

The  general  respiratory  expansion  is  distinctly  diminished;  there 
is  absence  of  resiliency  of  movement,  the  ribs  and  sternum  moving 
upward  (principally)  and  forward  (slightly)  as  if  made  of  one  piece. 
With  the  elevation  of  the  chest  the  hypertrophied  sternomastoids  and 
scaleni  jerk  out  tensely  into  greater  prominence,  the  supraclavicular, 
suprasternal,  and  upper  intercostal  spaces  being  correspondingly  deep- 
ened with  the  inspiration.  The  expiratory  movement  is,  on  the  other 
hand,  tardy,  slow,  and  labored,  and  the  spaces  just  mentioned  bulge 
out  during  forced  expiration.  The  lower  part  of  the  chest,  including 
the  diaphragmatic  region,  is  seen  to  be  retracted  during  inspiration, 
and  the  upper  bellies  of  the  recti  muscles  firmly  contracted;  indeed, 
the  breathing  movements  altogether  are  chiefly  abdominal  and  re- 
versed as  regards  the  excursions  of  the  mural  tissues  and  the  acts  of 
respiration.  The  diaphragmatic  shadow  (Litten's  sign)  is  faintly 
seen,  moves  but  an  interspace,  and  begins  at  the  eighth  interspace. 
During  quiet  breathing  the  sign  is  absent. 

Mensuration,  with  the  tape  line  around  the  chest  at  the  nipple 
level,  demonstrates  diminished  respiratory  expansion :  a  difference  of 
but  1£  in.  between  the  measurements  of  deepest  inspiration  and  deep- 


211 

est  expiration.  The  total  circumferential  measurement  of  the  thorax 
is  disproportionately  large :  the  patient's  stature  measures  5  ft.  8  in., 
the  thoracic  circumference,  41  in.,  and  the  man  is  not  obese  or  other- 
wise unusually  large  in  build. 

On  palpation,  the  signs  obtained  by  inspection  are  confirmed;  the 
extreme  hardness  and  rigidity  of  the  whole  bony  and  cartilaginous 
thorax,  the  lack  of  resiliency  and  expansibility,  are  especially  notice- 
able. The  vocal  fremitus  is  bilaterally  diminished.  Some  rhonchal 
fremitus  is  felt  over  the  region  of  the  main  bronchi  in  front  imme- 
diately after  a  coughing  spell.  Incidentally,  the  cardiac  apex-beat  is 
very  feebly  palpable,  while  a  moderately  marked  pulsation  in  the  epi- 
gastrium is  noted. 

Percussion  shows  a  distinct  hyperresonance  over  both  lungs,  with  a 
boardy  or  woodeny  quality.  Near  the  sternum  the  sound  has  a  slightly 
tynipanitic  tone.  The  quality  of  the  sound  is  not  changed  either 
by  a  forced  inspiration  or  expiration.  This  clear,  loud,  low-pitched 
resonance  is  discovered  to  extend  beyond  the  normal  boundaries  of  the 
lungs;  with  slightly  higher  pitch  it  is  heard  as  low  as  the  seventh 
rib  in  the  midclavicular  lines,  the  ninth  interspace  in  the  midaxillary, 
and  the  twelfth  rib  in  the  scapular  lines.  With  the  exception  of  a 
small,  indistinct  area  of  dulness  below  the  fifth  rib,  between  the 
sternum  and  the  left  mammillary  line,  no  cardiac  dulness  can  be 
found.  Over  the  sternum  itself  the  percussion  note  has  a  marked 
"box  tone"  (Schachtelton).  The  splenic  dulness  is  very  small  and 
indistinct,  and  begins  at  the  tenth  rib.  The  apices  manifest  a  vesic- 
ulotympany  on  percussion  that  is  best  perceived  during  the  bulging 
of  inspiration.  The  mobility  of  the  lower  borders  of  the  lungs,  as 
revealed  by  percussion  at  the  end  of  the  two  forced  respiratory  acts, 
is  practically  nil. 

Auscultation. — The  breath  sounds  over  the  vesicular  lung  sub- 
stance are  everywhere  soft,  and  so  feeble  in  places  as  to  be  scarcely 
audible.  The  most  striking  feature  is  marked  relative  prolongation 
and  weakness  of  the  expiratory  sound,  with  lowered  pitch,  the  short- 
ened inspiratory  sound  being  apparently  only  about  one-third  as  long 
as  the  expiratory.  A  few  sonorous  and  sibilant  rales  are  heard  near 
the  region  of  the  left  bronchus,  and  occasionally  some  high-pitched 
wheezing  during  expiration  near  the  vertebral  borders  of  the  scapulas, 
as  well  as  a  few  crackling  and  fine  moist  rales  near  the  bases  of  the 
lungs  posteriorly.  The  adjacent  heart  sounds  are  much  enfeebled  at 
the  normal  position  of  the  apex.  The  second  sound  at  the  pulmonary 
valve  area,  however,  is  relatively  sharpened  in  tone.  There  is  no 


212  PHYSICAL   DIAGNOSIS 

distinct  change  in  the  vocal  resonance,  although  if  anything  it  is  a. 
trifle  diminished. 

SYNTHETIC  ANALYSIS. — Inspection  and  mensuration  show  obvi- 
ously enough,  without  any  lengthy  discussion,  the  presence  of  some 
intrathoracic  condition  of  chronic  or  permanent  structural  change  as 
the  cause  of  so  great  and  general  enlargement,  and  yet  so  little  power 
of  expansion,  even  with  the  manifest  laboriousness  of  effort — a  dis- 
tention  of  capacity  with  restriction  of  activity.  Sometimes  we  meet 
with  large  chests  in  those  who  have  been  athletes  or  devotees  of. 
"  physical  culture,"  but  the  normal  contour  and  proportions  are  main- 
tained, and  the  respiratory  expansion  is  increased  instead  of  dimin- 
ished. Here  the  almost  fixed  enlargement  means  that  the  pleural 
sacs  are  distended  with  too  much  intrapulmonary  air,  or  with  a  bilat- 
eral effusion  of  liquid  or  air.  The  last-named  condition  practically 
never  occurs;  a  double  hydrothorax  is  very  rare,  and  so  here  pre- 
sumptively improbable;  besides,  a  pneumothorax  is  usually  unilateral 
and  associated  with  the  signs  of  advanced,  pulmonary  tuberculosis, 
and  the  bulging  of  a  pleural  effusion  is  most  marked,  and  likely  to 
be  limited  to  the  base  of  the  chest. 

In  addition  to  the  detailed  physical  signs,  visible  and  mensurable, 
that  correspond  closely  with  the  characteristics  of  the  emphysematous 
chest  previously  described,  the  inference  of  an  air-containing,  large- 
lunged  condition  is  confirmed  by  the  extensive  area  of  loud  vesiculo- 
tympany  on  percussion.  But  we  know  also  that  such  a  protracted 
history  of  pulmonary  strain  as  this  patient  gives,  with  his  having 
had  asthma  and  chronic  bronchitis  (rales)  for  so  many  years,  must 
have  left  its  impress  permanently  in  weakened  elasticity  as  well  as 
distended  capacity  of  the  alveolar  walls,  a  deduction  which  is  fully 
met  by  the  fact  that  the  breath  sounds  are  feeble  and  the  expiration 
much  prolonged ;  evidently  the  respiratory  murmur  cannot  be  distinct 
when  a  decreased  amount  of  inspired  air  can  enter  the  already  filled 
vesicles,  and  when  that  which  is  expired  has  so  little  alveolar  reactive 
tension  left  to  create  any  prompt,  brief,  or  sharply  audible  current 
in  passing. 

The  diagnosis  of  liypertropliic  emphysema  of  the  lungs  is  estab- 
lished also  by  the  characteristic  border  features,  especially  the  ex- 
tended and  yet  almost  immobile  lung  boundaries,  and  the  effects  of 
their  encroachment  upon  the  areas  of  dulness  of  the  heart,  liver,  and 
spleen. 

DIFFERENTIAL  DIAGNOSIS. — Pneumothorax  is  the  only  condition 
that  may  simulate  emphysema  to  any  appreciable  extent,  but,  in  the 


HYPOTHETICAL  AXD  RECORDED  CASES    213 

first  place,,  the  former  is  apt  to  be  sudden  and  abrupt  rather  than 
gradual  and  long  continued  in  its  development,  as  in  the  case  of 
emphysema.  Then,  again,  pneumothorax  is  unilateral;  the  enlarge- 
ment is  one-sided,  and  the  affected  side  hardly  moves  at  all.  The 
thorax  is  also  generally  small  and  emaciated.  The  unaffected  side 
moves  with  exaggerated  activity.  The  percussion  note  is  more  often 
tympanitic  than  simply  hyperresonant,  and  is  more  apt  to  displace 
the  heart  (in  a  direction  opposite  to  pressure)  than  is  emphysema, 
which  encroaches  over  the  adjacent  organs.  Whereas  in  emphysema 
feeble  breathing  is  heard,  associated  with  whistling  or  fine  bubbling 
rales,  in  pneumothorax  the  breath  sounds  are  either  absent  over  the 
affected  side,  or  distant  amphoric  breathing,  possibly  with  metallic 
tinkling,  is  detected.  The  coin-percussion  test  may  reveal  the  me- 
tallic or  bell  sound  peculiar  to  pneumothorax.  And,  finally,  a  zone 
of  dulness  at  the  base  posterolaterally,  the  upper  limit  changing  with 
the  posture  of  the  patient,  may  indicate  the  presence  of  liquid  (hydro- 
pneumothorax). 

It  is  highly  important  that  other  conditions  than  emphysema, 
which  ma}-  be  partially  hidden  by  the  enlarged  and  extended  lungs, 
should  be  sought  for  in  most  cases.  Thus  aortic  aneurisms,  medias- 
tinal  tumors,  cardiac,  hepatic,  and  splenic  enlargements,  pulmonary 
tuberculosis,  and  bronchiectatic  cavities,  for  example,  may  be  over- 
looked in  consequence. 


SECTION    III 

THE  HEART   AND   PERICARDIUM 


CHAPTEE    IX 
INSPECTION 

Preliminary. — There  is  no  organ  of  the  chest  or  abdomen  the 
anatomic  and  functional  abnormalities  of  which  lend  themselves  so 
readily  and  accurately  to  diagnosis  by  means  of  the  physical  methods 
of  examination  as  the  heart.  The  physical  diagnosis  of  cardiac  affec- 
tions is  also  the  most  important,  in  an  individual  or  exclusive  sense, 
in  that  the  physical  signs  of  themselves  are  essential  to  a  precise 
knowledge  of  the  lesions.  Furthermore,  given  the  signs  of  a  case 
of  organic  valvular  disease,  for  example,  and  the  location  and  charac- 
ter of  the  disorder,  with  its  consequences  upon  the  pulmonary  and 
systemic  circulations,  especially  in  the  way  of  engorgements,  may  be 
deduced  by  an  Aristotelian  logic  with  almost  mathematical  precision. 

Before  any  satisfactory  information  concerning  the  diagnosis  of 
cardiac  diseases  can  be  utilized,  a  review  of  the  cardinal  points  of 
the  clinical  anatomy  of  the  heart  is  of  prime  importance,  since  much 
depends  upon  this.  Likewise  the  physiology  of  the  heart  has  vital 
bearing  upon  the  diagnosis  of  most  of  its  affections,  but  this  will  be 
considered  more  appropriately  under  auscultation. 

TOPOGRAPHIC    AND    RELATIONAL   ANATOMY    OF 
THE    HEART    AND    ITS    VALVES 

Location  of  the  Heart. — The  heart  being  conoidal  or  irregularly 
pyramidal  in  shape,  is  so  located  between  the  anterior  and  posterior 
mediastini  that  its  long  axis  is  directed  downward,  forward,  and  to 
the  left  (at  an  angle  of  60  degrees  with  that  of  the  body),  its  apex 
behind  the  fifth  interspace,  |  to  1  in.  inside  the  left  nipple  line,  the 
214 


215 


base  directed  upward,  backward,  and  to  the  right  side,  its  extreme 
border  extending  about  1  in.  to  the  right  of  the  right  sternal  line 
(fourth  interspace).  Its  lower  surface  rests  upon  the  central  tendon 
of  the  diaphragm.  Thus  two-thirds  of  the  organ,  sometimes  three- 


FIG.  42. — THE  ANTERIOR  ASPECT  OF  THE  NORMAL  HEART  AXD  GREAT  VESSELS,  SHOW- 
ING THEIR  RELATIONS  TO  THE  ANATOMIC  LANDMARKS  (Hiss,  STERNUM,  CLAVI- 
CLES) OF  THE  FRONT  OF  THE  THORAX.  (Butler.) 

fourths,  is  on  the  left  side.  It  is  held  from  rolling  about  in  the  chest 
by  its  attachments  to  the  great  vessels  at  the  base,  and  by  the  peri- 
cardial  sac  which  envelops  it  firmly  around  the  roots  of  the  vessels, 
loosely  below,  leaving  some  space  between  the  heart  (right  ventricle) 
and  its  diaphragmatic  and  sternal  attachments  analogous  to  the  com- 
plementary pleural  sinus. 


216  PHYSICAL    DIAGNOSIS 

The  relations  of  the  anterior  surface  of  the  heart  to  the  chest 
wall  in  front  are  of  most  practical  importance.  This  slightly  curved 
surface  is  nearly  parallel  to,  and  in  apposition  with,  the  sternum  and 
ribs,  except  where  the  lungs  overlap  by  their  anterior  borders,  and 
is  triangular  in  shape.  It  includes  the  right  appendix  and  most  of 
the  right  auricle  to  the  right  of  the  midsternal  line,  the  greater  part 
of  the  right  ventricle  (a  portion  uncovered  by  lung),  and  small  por- 
tions of  the  left  appendix  and  left  ventricle  to  the  left  of  the  same 
line. 

Topographic  Outline  of  the  Heart  on  the  Chest  Wall. — Assum- 
ing the  examiner's  eyes  to  be  on  a  level  with  the  center  of  the  heart, 
approximately — that  is,  opposite  the  left  border  of  the  sternum  in  the 
fourth  interspace — the  surface  landmarks  of  the  borders  of  the  aver- 
age normal  heart  may  be  projected  as  follows : 

(1)  Upper  Border. — This  may  be  denned  by  a  horizontal  line 
drawn  through  the  upper  edge  of  the  third  costal  cartilages,  extending 
from  a  point  1  in.  to  the  left  of  the  left  sternal  margin  to  a  point 
^  in.   to  the  right   of  the  right  sternochondral  articulation.     This 
defines  the  highest  point  of  the  heart — the  base — above  which  are  the 
great  vessels,  and  below  which  run  the  right  and  left  boundaries, 
more  or  less  outwardly. 

(2)  Bight  Border. — This  is  traced  by  a  line  curving  outward 
slightly  from  the  right  upper  point,  just  noted,  down  to  the  lower 
border  of  the  fifth  rib,  nearly  1  in.  to  the  right  of  the  edge  of  the 
breast-bone.     From  -thence,  curving  sharply  inward,  begins  the 

(3)  Lower   Border. — It    slopes    downward    slightly    toward    the 
left,  crossing  the  midsternal  line  at  the  junction  of  the  upper  and 
middle    thirds    of    the    xiphoid   process,    the    sixth    costal    cartilage 
(left)   near  the  sternal  junction,  and  terminates  in  the  fifth  inter- 
space near  the  apex,  about  1  in.  within  the  midclavicular  or  mam- 
millary  line. 

(4)  Left,  or  Outer,  Border. — This  corresponds  with  an  oblique, 
slightly  curved  line,  with  its  convexity  outward,  extending  from  the 
left  end  of  the  upper  boundary  (1  or  1^  in.  to  the  left  of  the  left 
sternal   articulation  of  the  third  costal  cartilage)    to  the  apex  in 
the  fifth  interspace,  about  3£  in.  from  the  midsternal  line. 

The  highest  point  of  the  heart,  the  left  auricle,  is  at  the  lower 
border  of  the  sternal  insertion  of  the  second  rib.  The  upper  boundary 
or  base  line  is  the  dividing  line  between  the  heart  and  the  great 
vessels  arising  from  it.  The  base  line  passes  through  the  tops  of 
the  auricles. 


INSPECTION  217 

The  right  border  is  formed  by  the  right  auricle  (behind  the 
sternum). 

The  iiifn-ior  border  is  formed  by  the  right  ventricle  and  apical 
portion  of  the  left  ventricle,  and  is  often  spoken  of  as  the  anatomic 
base  of  the  heart,  in  contradistinction  to  the  commonly  accepted 
clinii'ti!  btixt\  with  its  great  vascular  attachments. 

The  left  border  is  formed  exclusively  by  the  deeper-seated  left 
ventricle. 

Posteriorly,  the  base  of  the  heart  corresponds  with  the  level 
of  the  fifth  or  sixth  dorsal  vertebra,  the  apex  with  the  eighth 
vertebra. 

According  to  Broadbent,  a  diagonal  line  extending  from  the  junc- 
tion of  the  third  costal  cartilage  with  the  left  edge  of  the  sternum 
downward  to  the  seventh  right  chondrosternal  articulation  represents 
the  usual  position  of  the  auriculoventricular  septum. 

Another  line,  passing  downward  from  inside  the  third  left  costo- 
chondral  articulation  to  a  point  about  ^  in.  within  the  apex  limit, 
corresponds  pretty  closely  with  the  course  of  the  interventricular 
septum. 

The  relations  which  the  different  parts  of  the  heart  bear  to  the 
chest  wall  need  to  be  considered  also. 

Beginning  above,  the  roots  of  the  great  vessels  lie  directly  behind 
the  sternum,  near  the  junction  of  the  third  left  costal  cartilage,  the 
origin  of  the  pulmonary  artery  being  almost  directly  in  front  of  that 
of  the  aorta. 

Viewing  the  uncovered  heart  in  situ,  one  discovers  the  lower  two- 
thirds  of  the  right  auricle  to  the  right  of  the  sternum,  the  upper 
third  behind  that  bone.  The  left  auricle  is  hidden  behind  the  right, 
except  at  its  tip,  which  may  be  seen  in  the  second  left  interspace 
close  to  the  sternal  edge.  The  right  ventricle  occupies  all  of  the 
remaining  triangular  space  anteriorly,  partly  behind  the  sternum  and 
partly  to  the  left  of  it,  the  narrow  margin  of  the  left  ventricle  pro- 
jecting from  behind  the  right  at  its  left  border,  and  terminating 
forward  at  the  apex. 

Positions  of  the  Great  Vessels. — The  pulmonary  artery  arises  at 
the  level  of  the  third  left  sternochondral  junction,  passes  upward 
close  to  the  left  edge  cf  the  sternum  for  nearly  2  in.,  to  end  behind 
the  second  left  costal  cartilage,  where  it  bifurcates.  The  aorta  (as- 
cending) begins  at  the  level  of  the  third  left  chondrosternal  articula- 
tion, and  takes  a  course  diagonally  upward  across  the  breast-bone  to 
the  second  right  chondrosternal  articulation,  projecting  somewhat  into 


218  PHYSICAL   DIAGNOSIS 

the  second  interspace.  The  arch  of  the  aorta  lies  back  of  the  sternum, 
its  transverse  portion  crossing  at  the  level  of  the  first  intercostal 
space;  posteriorly,  its  highest  part  reaches  the  level  of  the  third 
dorsal  vertebra.  The  aorta  reaches  the  spine  at  the  fourth  dorsal 
vertebra,  at  which  level  the  pulmonary  artery  and  trachea  both 
bifurcate. 

The  innominate  artery  arises  opposite  the  first  intercostal  space 
behind  the  left  half  of  the  sternum.  It  ascends  obliquely  to  the  right 
sternoclavicular  articulation,  where  it  divides  into  the  right  common 
carotid  and  subclavian  arteries. 

The  superior  vena  cava  lies  to  the  right  of  the  aortic  arch,  about 
|  in.  to  the  right  of  the  right  sternal  border,  passing  downward  from 
the  first  costal  cartilage  to  the  second  intercostal  space. 
V  Relations  of  the  Heart  to  the  Lungs. — The  whole  of  the  anterior 
surface  of  the  heart  is  overlapped  by  lung,  except  that  irregularly 
triangular,  almost  quadrilateral  space  corresponding  to  the  lower  por- 
tion of  the  right  ventricle,  due  to  the  indentation  of  the  anterior  edge 
of  the  left  lung.  It  may  be  well  to  recall  the  relations  of  the  lung 
margins  to  the  enveloped  heart.  The  anterior  borders  of  the  lungs, 
descending  from  the  apices,  approach  each  other  until  they  almost 
meet  behind  the  middle  of  the  sternum  at  the  level  of  the  second 
costal  cartilage,  whence  they  descend,  closely  apposed  to  each  other, 
to  the  fourth  chondral  level.  At  this  point  they  diverge,  the  right 
lung  border  passing  gradually  downward  and  outward,  to  cross  the 
fifth  cartilage  and  interspace,  and  meet  the  inferior  border  at  the 
sixth  rib  in  the  midclavicular  line ;  the  left,  turning  abruptly  outward 
at  the  fourth  chondral  level,  passes  along  the  lower  margin  of  the 
same,  obliquely  crossing  the  fourth  interspace  near  the  parasternal 
line  (almost  corresponding  to  the  costochondral  junction),  then  turn- 
ing slightly  inward,  like  a  reversed  letter  s,  and  again  downward  and 
outward  across  the  fifth  rib  and  interspace,  unites  with  the  inferior 
border  at  the  sixth  rib  as  on  the  right  side. 

Thus  the  boundaries  of  this  superficial  portion  of  the  heart  are 
as  follows :  the  upper,  at  the  lower  border  of  the  left  fourth  rib ;  the 
right,  between  the  middle  line  and  the  left  sternal  line;  the  left,  a 
little  outside  the  left  parasternal  line,  below  the  fifth  interspace, 
where  the  heart  overlaps  the  left  lobe  of  the  liver.  It  js_Jjiis  portion 
of  the  heart  (right  ventricle)  in  contact  with  the  chest  wall  which, 
on  percussion,  gives  rise  to  the  so-called  area  of  absolute  or  mtpcr- 
fi<ial_  cardia£_dulness.  Should  the  lung  here  completely  fill  the 
complementary  plcural  sinus,  this  relatively  exposed  region  of  the 


219 


heart  would  be  much  smaller  than  the  approximately  2|  X  2^ 
in.  area. 

Positions  of  the  Valves. — These  are  pretty  close  together,  topo- 
graphically, bunched,  as  it  were,  near  the  junctions  of  the  third  and 
fourth  ribs  (left)  and  the  third  interspace  with  the  sternum.  The 
pulmonary  valve  point  is  the  most  superficial  and  superior,  the  tri- 
cuspid  the  most  inferior,  the  aortic  the  most  central,  and  the  mitral 
the  most  outer  and  internal. 

More  precisely,  the  valves  may  be  located  according  to  the  follow- 
ing topography.  The  mitral  valve,  the  most  deeply  seated  of  all,  is 


FIG.  43. — POSITION  OF  THE  CARDIAC  ORIFICES  IN  RELATION  TO  THE  StmrACE  OF  THE 
CHEST.     (Gibson  and  Russell.) 


behind  the  left  half  of  the  sternum,  on  a  level  with  the  third  inter- 
space, fourth  cartilage,  and  fourth  interspace. 

The  tricuspid,  the  other  auriculoventricular  valve,  lowest  in  situ- 
ation, is  behind  the  middle  of  the  lower  fourth  of  the  sternum,  corre- 
sponding to  the  fourth  and  fifth  cartilages  and  the  fourth  interspace. 

The  aortic  valve,  most  centrally  located,  lies  behind  the  left  half 
of  the  breast-bone,  on  a  level  with  the  third  interspace  and  the  lower 
portion  of  the  third  costal  cartilage. 

The  pulmonary  valve  lies  in  front  of  part  of  the  aortic,  but  a 


220  PHYSICAL    DIAGNOSIS 

little  higher  and  more  to  the  left;  its  level  is  the  third  cartilage,  and 
a  needle  pushed  horizontally  through  the  third  left  chondrosternal 
junction  would  ahout  penetrate  the  middle  of  the  pulmonary  orifice. 

A  stethoscope,  with  a  chest  piece  a  little  over  1  in.  in  diameter, 
placed  with  its  outer  edge  coinciding  with  the  left  sternal  margin  and 
its  upper  and  diametrically  lower  limits  corresponding  to  the  levels 
of  the  middle  of  the  third  and  fourth  costal  cartilages  respectively, 
will  include  a  portion  of  all  four  valves.  But,  as  will  be  pointed  out 
later,  under  auscultation  these  anatomic  surface  landmarks  do  not 
correspond  to  the  areas  at  which  the  sounds  produced  by  valve  closure 
are  usually  best  heard. 

Furthermore,  the  chest  outlines  of  the  heart  vary  somewhat  in 
health  owing  to  its  normal  mobility,  swinging  as  it  may  from  right 
to  left,  up  and  down,  forward  and  backward,  from  its  base  with 
vascular  attachments.  This  may  result  from  posture  and  from  re- 
spiratory movement,  the  changes  affecting  the  outer  border  and  apex 
principally.  The  left  lateral  and  dorsal  positions  are  most  apt  to 
alter  the  relation  of  the  heart  to  the  external  landmarks.  The  move- 
ments, upward  and  downward,  of  the  ribs  and  diaphragm  rhythmic- 
ally affect  the  upper  and  lower  boundary  relations  only  with  forced 
respiration,  for  which  due  allowance  may  be  made. 

Age  is  a  factor,  also,  in  that  with  children  the  heart  is  about  one 
rib  higher,  and  has  a  trifle  more  surface  in  contact  with  the  chest  wall 
because  of  less  volume  of  overlapping  lung  proportionately.  On  the 
other  hand,  in  the  aged  the  heart  moves  lower  down,  so  that  its 
inferior  limit  corresponds  with  the  lower  border  of  the  sixth 
rib,  or  even  the  sixth  interspace.  On  account  of  the  increased 
volume  of  lung,  however,  a  smaller  portion  of  the  heart  is  parietal, 
proportionately,  than  during  the  early  and  later  middle  years 
of  life. 

The  Precordium. — From  the  preceding  data  of  the  clinical  anat- 
omy of  the  heart,  it  will  appear  that  practically  all  of  the  physical 
signs  referable  to  diseases  of  this  organ  occur  within  a  limited,  rather 
definite,  area  of  the  chest  wall — the  precordium.  This  precordial 
space,  for  ordinary  purposes,  constitutes  a  somewhat  arbitrary  rectan- 
gular area  whose  upper  boundary  is  the  second  rib;  its  inner  boundary, 
a  vertical  line  1  in.  to  the  right  of  the  right  border  of  the  sternum; 
its  outer  boundary,  a  vertical  line  coinciding  with  the  left  midclavicu- 
lar  or  nipple  line;  its  lower  boundary,  parallel  with  the  horizontal 
upper,  and  passing  through  the  sixth  rib  at  the  level  of  intersection 
with  the  preceding  or  mammillary  line. 


INSPECTION  221 


METHOD    OF    INSPECTION    OF   THE    HEART 

As  in  the  examination  of  the  chest,  as  a  whole,  with  a  view  to 
ascertaining  the  physical  signs  of  pulmonary  diseases,  so  here  it  is 
essential  for  satisfactory  results  that  the  whole  precordial  and  sur- 
rounding area  be  exposed  to  vision  under  both  direct  and  oblique 
light — preferably  daylight.  For  accuracy,  the  patient  should  be  ex- 
amined in  both  the  sitting  or  standing  and  semirecumbent  positions. 

In  the  inspection  of  the  precordium  we  observe  this  region  as  a 
whole;  then  any  of  its  individual  constituent  features.  The  normal 
chest  shows  the  slight  flattening  over  the  sternal  area,  and  a  symmet- 
rical fulness  of  the  two  sides  and  of  the  rhythmical  respiratory  rise 
and  fall;  between  the  fifth  and  sixth  ribs,  about  2  in.  from  the  left 
edge  of  the  breast-bone,  a  slight  thrusting  movement,  hardly  more 
than  |  in.  in  diameter,  is  visible.  These  impulses  average  about 
four  to  one  respiratory  movement.  In  some  healthy  individuals  the 
precordium  is  a  trifle  fuller  than  the  corresponding  region  on  the 
opposite  side,  occasionally  due  to  greater  muscular  development  in  a 
left-handed  person.  Just  as  often,  perhaps,  if  not  more  so,  this  area 
shows  a  little  flatter  aspect  than  on  the  right  side.  In  many,  also, 
a  slight  pulsation  may  be  seen  in  the  epigastrium,  just  below  the 
tip  of  the  ensiform  cartilage,  especially  after  exertion  or  during  a 
certain  amount  of  mental  activity  or  emotional  excitement. 

We  study:  (1)  Abnormal  prominence  or  depression  of  the  precor- 
dium; (2)  abnormal  pulsations  within  or  near  the  borders  of  this 
space;  (3)  most  important  of  all,  the  apex-beat. 

(1)  The  Precordium  and  its  Adjacent  Areas  in  General. — (a) 
UNDUE  PROMINENCE. — This  is  the  most  common  change  in  the  form. 
Allowance  must  be  made  for  alterations  not  cardiac  but  costal  or 
inflammatory  in  origin.  Thus,  such  malformations  as  may  be  asso- 
ciated with  spinal  curvature,  rickets,  fractures,  bony  and  cartilaginous 
hypertrophies,  and  tumors  and  the  like  must  be  differentiated.  The 
same  is  true  with  regard  to  the  unilateral  or  local  bulgings  due  to 
pulmonary  or  pleural  diseases. 

Of  strictly  cardiac  causation,  the  most  common  source  of  abnormal 
precordial  fulness  is  enlargement  of  the  organ — that  condition  of 
combined  thickening  of  the  walls  and  increase  of  chamber  capacity 
known  as  hypertrophic  dilation  of  the  heart.  The  degree  of  bulging 
is  usually  quite  moderate,  and  distinctly  more  noticeable  in  childhood 
with  its  thinner,  yielding  thoracic  walls.  In  adults,  especially  those 


222  PHYSICAL   DIAGNOSIS 

past  middle  life,  only  the  greatest  enlargements  of  the  heart  cause 
marked  precordial  bulging,  provided,  as  a  rule,  that  the  condition 
is  one  of  long  standing.  A  moderate  or  slight  bulging,  therefore, 
limited  to  the  lower  half  of  the  precordial  space,  but  unaccompanied 
with  a  filling  out  of  the  contained  interspaces,  occurring  especially 
in  a  person  who  has  not  reached  middle  life  and  who  complains  of 
breathlessness  on  a  little  exertion,  is  in  itself  significant  of  the  proba- 
bility of  cardiac  hypertrophy  due  to  some  valvular  lesion. 

When  the  alteration  of  the  form  of  the  precordium  is  more  gen- 
eral, the  prominence  more  marked,  and  unmistakable  fulness  of  the 
intercostal  spaces  also  evident,  it  points  to  the  presence  of  a  pcri- 
cardial  effusion.  Of  course,  this  precordial  swelling  is  noticeable 
not  so  much  as  an  independent  as  a  comparative  sign — the  fact  that 
it  does  not  extend  beyond  the  sternum,  to  the  right;  that  it  is  usually 
seen  farther  to  the  left — beyond  the  nipple  line;  farther  down — to 
the  sixth  interspace  at  times;  and  higher — to  the  third,  even  second 
interspace  in  severe  cases,  than  where  enlargement  of  the  heart  is 
the  cause.  Also,  the  younger  the  patient  the  more  prominent  the 
effect  of  a  pericardial  effusion  upon  the  precordial  shape. 

Local  bulgings  above  the  fourth  rib  are  almost  invariably  aneu- 
rismal.  It  is  considered  quite  characteristic  of  aneurism  of  the  in- 
nominate artery  to  find  a  rounded  swelling  in  the  suprasternal  notch 
and  behind  the  right  sternoclavicular  articulation,  the  sternal  end  of 
the  collar-bone  being  even  dislocated  forward  in  some  cases,  and 
pulsating.  Bulging  in  the  first  and  second  right  interspaces  near  the 
sternal  margin,  or  of  the  manubrium  and  second  and  third  costal 
cartilages  on  both  sides,  indicates  pressure  and  erosion  from  aneurism 
either  of  the  ascending  or  transverse  aortic  arch. 

(6)  ABNORMAL  DEPRESSION  OF  THE  PRECORDIUM  is  sometimes 
seen.  Aside  from  the  collateral  effect  of  scoliotic  or  rachitic  deformi- 
ties of  the  thorax,  and  of  unilateral  chronic  pleural  adhesions  with  or 
without  an  old,  left-sided  empyema,  a  portion  of  the  precordium  may 
be  sunken  because  of  adherent  pericardium  following  chronic  peri- 
carditis. The  superjacent  pleura  may  also  be  attached  to  the  region 
of  adhesion  of  the  visceral  and  parietal  layers  of  the  pericardium, 
thus  aggravating  the  retracted  area. 

(2)  Abnormal  Precordial  Pulsations. — Apart  from  the  normal 
and  abnormal  apex-beat  (to  be  considered  under  the  next  article),  all 
other  precordial  pulsations  visible  (or  palpable)  are  adventitious — 
abnormal — and  more  or  less  significant  of  cardiac  derangement,  aortic 
disease  (aneurism),  or  adjacent  pleuropulmonary  disease. 


INSPECTION  223 

(a)  AT  THE  BASE  AND  BORDERS  OF  THE  HEART. — Pulsations  here 
may  indicate  aortic  aneurism,  enlargement  of  the  heart  (auricles),  or 
exposure  of  the  aorta  and  pulmonary  artery  from  shrinking  of  the 
lungs  due  to  fibroid  phthisis  or  chronic  pleurisy  with  adhesions. 

Many  of  these  pulsations  are  more  evident  when  viewed  at  an 
angle,  as  from  the  side  of  the  patient's  bed.  The  natural  visibility 
of  new  pulsations  and  their  rhythmical  relation  to  the  apical  impulse 
may  be  determined  and  confirmed  with  greater  accuracy  by  such  avail- 
able artificial  means  as  the  following :  Balfour  attaches  a  short  bristle 
carrying  a  tiny  paper  flag,  by  means  of  a  pellet  of  beeswax,  to  the 
skin  over  the  pulsation  whose  time  in  the  cardiac  cycle  (systole  or 
diastole)  is  to  be  determined,  and  a  similar  flag  is  placed  over  the 
apex-beat;  the  consequent  exaggeration  of  these  pulsations  in  the 
movements  of  the  flag  extremities  enables  the  eye  to  detect  more 
positively  the  slight  or  doubtful  new  pulsations,  as  well  as  to  dis- 
criminate any  difference  in  time  in  the  movements  of  the  flags.  An- 
other method,  simpler  and  readier,  is  to  pull  bits  of  absorbent  cotton 
into  slender  cones  2  or  3  in.  long,  then  apply  their  bases  to  the  skin 
over  the  pulsating  spots,  previously  touched  with  mucilage  or  thick 
ointment  (Butler).  The  expansile  (aneurismal)  character  of  a  pul- 
sation may  also  be  noted  by  placing  indicators  on  diametrically  oppo- 
site sides  of  the  pulsating  tumor,  and  observing  the  divergence  and 
convergence  of  their  tips  with  expansion  and  contraction  respectively. 

As  the  base  of  the  heart  is  completely  covered  by  lung,  as  it  moves 
backward  with  each  systole,  and  as  its  impulse  is  transmitted  with 
difficulty,  also,  because  of  the  resistance  and  thickness  of  the  ribs 
(including  the  pectoral  muscles  and  adipose  tissue)  in  that  region, 
any  base  beat  here — that  is,  practically  above  the  level  of  the  fourth 
rib — must  mean  either  retraction  of  the  lungs,  enlargement  of  one 
or  more  heart  chambers,  especially  in  children  with  thin,  elastic  chest 
walls,  or  some  dynamic  or  aneurismal  affection  of  the  great  arteries. 

The  pathologic  significance  of  pulsations  occurring  in  parts  other 
than  the  apical  region  of  the  heart  may  now  be  dealt  with  seriatim. 

In  the  suprasternal  notch,  abnormal  pulsations  may  be  due  to 
aneurism  either  of  the  innominate  artery  or  of  the  transverse  portion 
of  the  arch  of  the  aorta.  I  have  witnessed  it  also  in  chlorotic  women 
with  soft,  flabby  arterial  walls  and  slow,  sluggish  heart  action. 

Pulsation  in  the  right  first  or  second  intercostal  space,  near  the 
sternal  border,  if  expansile,  systolic  in  time,  and  accompanied  with 
some  swelling,  perhaps,  is  indicative  of  aneurism  of  the  ascending 
portion  of  the  aortic  arch.  If  the  expansile  character  of  the  pulsa- 


224 


PHYSICAL    DIAGNOSIS 


tion  is  absent,  the  movement  may  be  due  either  to  transmitted  violent 
cardiac  action  or  to  exposure  of  the  aorta  in  cases  where  the  heart 
is  drawn  to  the  right  by  right-sided  pleuritic  adhesions  with  re- 
tracted lung. 

Pulsation  in  the  right  second,  third,  and  fourth  interspaces  may 
be  partly  due  to  the  last-named  condition  or  to  throbbing  of  the  right 


APEX  BEAT  DISPLACE D- 


UP  AND  TO  LEFT 
PERICARDIAL  EFFUSION 
ABDOMINAL  DISTENTION 
FlBROSIS    OR    CONTRACT- 
ING CAVITY,  LEFT  LUNQ 
EXTENSIVE  LEFT  PLEURAL 

ADHESIONS 
FLUID    OR  AIR    IN   RIGHT 

PLEURA 


EPIGASTRIC    PULSATION 

SYSTOLIC  (HEART)  POST-SYSTOLIC  (AORTA) 

ENLARGED  RIGHT  VENTRICLE 
EMPHYSEMA  BATHYCA::DIA 
SIMPLE  OVERACTION  OF  HEART 
DISPLACED  APEX  BEAT 


THROBBING  AORTA 

THIN    ABDOMINAL   WALLS 

TUMOUR  IN  PRONT  OF  AORTA 
ABDOMINAL  ANEURISM 


RIGHT  VENTRICULAR 
HYPERTROPHY  AND 
DILATATION 


FIG.  44. — SHOWING  THE  INDICATIONS  TO  BE  OBTAINED  FROM  THE  POSITION  OF  THE 
APEX-BEAT  AND  OTHER  THORACIC  AND  EPIGASTRIC  PULSATIONS.  I,  II,  III,  IV, 
V,  VI  =  pulsations  of  aortic  aneurism  (arch),  numbered  in  order  of  frequency 
of  occurrence.  VII  =  innominate  aneurism.  11  =  also  pulsation  of  pulmonary 
artery  (and  left  auricular  appendix?).  F  =  also  pulsation  of  right  ventricle 
(and  left  auricular  appendix?).  O=  cardiac  impulses.  +  =aneurismal  pulsa- 
tions. ©=both.  (Butler.) 

auricle   (presystolic  in  time),  which  is  usually  dilated  because  of 
secondary  tricuspid  regurgitation  in  such  instances. 

Pulsations  in  the  right  third,  fourth,  and  fifth  interspaces,  near 
the  right  parasternal  or  midclavicular  lines,  are  the  result  of  dis- 


INSPECTION  225 

placed  heart  to  the  right,  either  from  the  pulling  forces  of  right- 
sided  pleural  and  pulmonary  adhesion  and  retraction  or  the  pushing 
effects  of  a  large  liquid  pleural  effusion,  or  of  a  pneumothorax  on 
the  left  side. 

Pulsation  over  the  manubrium  indicates  eroding  aneurism  of  the 
innominate  artery,  or  of  the  transverse  portion  of  the  arch  of  the 
aorta. 

Pulsations  detected  in  the  left  second  or  third  interspace,  close  to 
the  margin  of  the  breast-bone,  may  be  arterial  (pulmonary),  aneu- 
rismal  (aortic),  or  auricular  (left).  In  the  two  first  cases  the  pulsa- 
tions are  synchronous  with  or  follow  slightly  the  apex-beat;  in  the 
third  they  precede  the  apex-beat  a  trifle.  If  there  are  simultaneous 
physical  signs  of  shrinking  of  the  left  lung,  or  of  enlargement  of  the 
heart,  the  pulsation  is  probably  due,  in  the  first  instance,  to  its  un- 
covered contact  with  the  walls  of  the  interspaces,  or  to  its  ready 
transmission  through  condensed  lung  structure  overlying,  and,  in  the 
second  instance,  to  a  markedly  dilated  and  engorged  left  auricle  or 
conus  arteriosus  of  the  pulmonary  artery,  as  is  found  in  mitral  steno- 
sis. Aneurismal  pulsation  in  this  region  would  mean,  obviously, 
involvement  of  the  descending  aorta. 

Pulsations  in  the  third,  fourth,  and  fifth  interspaces,  between  the 
left  edge  of  the  sternum  and  the  left  parasternal  line,  are  due  to 
hypertrophic  dilation  of  the  right  ventricle,  or  to  the  very  rare  aneu- 
rism of  the  ventricular  wall. 

Pulsations  in  the  third  and  fourth  interspaces,  in  or  slightly 
outside  the  left  midclavicular  line,  usually  mean  a  displaced 
apex-beat. 

Occasionally  a  double  impulse,  accompanying  with  more  or  less 
regularity  each  systole,  has  been  observed  (Guttmann,  Leyden,  and 
others).  It  occurs  in  aggravated  cases  of  mitral  insufficiency,  and 
arises  from  the  non-coincidence  of  the  contractions  of  the  ventricles. 
The  pulsation  in  the  carotid  artery  corresponds  with  the  first  of  these 
strokes  only. 

Extent. — The  wider  the  area  of  impulse  over  the  precordium — 
that  is,  one  diffused  broadly  in  two  or  three  interspaces — the  greater, 
as  a  rule,  the  hypertrophy  of  the  heart.  Unless  the  heart  is  displaced 
to  the  left,  however,  the  pulsations  do  not  extend  beyond  the  left 
mammillary  line.  In  cases  where  the  chest  wall  is  very  thin  and 
flexible,  the  pulsation  may  be  quite  diffused  even  with  a  normal  size 
of  the  heart,  particularly  if  its  action  is  excited  and  the  overlying 

lung  thin  or  retracted. 
27 


226  PHYSICAL    DIAGNOSIS 

(6)  SYSTOLIC  RETRACTION. — Before  taking  up  the  extracardiac 
border-line  pulsations,  this  precordial,  rhythmical  sinking  in,  instead 
of  thrusting  out,  may  be  considered.  It  affects  usually  the  third, 
fourth,  and  fifth  interspaces  on  the  left  side,  over  the  body  of  the 
heart,  around  the  apex-beat,  and  the  left  xiphochondral  angular  space. 
Its  significance  is  adhesive  pericarditis. 

(c)  BROADBENT'S   SIGN. — A  systolic  recession  of  the  tenth  and 
eleventh  interspaces,  below  the  inferior  angle  of  the  scapula,   was 
described  by  Sir  William  Broadbent  as  a  sign  of  adherent  pericar- 
dium.    It  is  seen  in  thin  or  emaciated  individuals.     It  is  explained 
as  the  result  of  a  drawing  upon  the  diaphragm  by  a  hypertrophied 
and    vigorously    acting    heart.      It   is    conceivably    an   exaggeration 
of    the    normal    but    invisible    slight    pull    which    the    heart   makes 
during  systole  upon  the  central  tendon  of  the  diaphragm.     Broad- 
bent's   sign   is  not  limited   to   an   indication   of   extensive   pericar- 
dial    adhesions,   however,    as    it   is    sometimes    present   in   cases    of 
marked  cardiac  hypertrophy  without  the  least  suspicion  or  evidence 
of  these. 

Pulsation  near  the  left  border  of  the  heart  may  be  due  to  a  "  pul- 
sating empyema"  (empyema  pulsans)  lying  close  thereto,  the  prob- 
ably tense  collection  of  pus  transmitting  the  heart's  impulse  to  the 
adjacent  interspaces. 

Similarly,  a  perceptible  pulsation  may  be  seen  in  this  region  in 
certain  cases  of  malignant  vascular  tumor  of  the  lung. 

Again,  hepatized  lung,  as  in  lobar  pneumonia,  may  convey  to  the 
surface  of  the  chest,  in  the  neighborhood  of  the  heart,  visible  fine 
pulsatory  movements  or  thrills  wherever  it  may  happen  to  be  in  inti- 
mate contact  with  the  latter  organ. 

(d)  EPIGASTRIC  PULSATION. — Very  important  is  the  occurrence 
of  abnormal  pulsation  in  this  extracardiac  region,  bounded  by  the 
costochondral  sides  of  the  epigastric  angle  forming  at  the  xiphoid 
cartilage.     A  throbbing  pulsation  in  the  epigastrium  may,  however, 
be  the  simple,  temporary,  physiologic  result  of  emotional  excitement 
or  sharp  physical  exercise,  as  a  run  up  a  flight  of  stairs  just  previous 
to  examination.     Pathologic  epigastric  pulsations  have  as   more  or 
less    probable    causes    the   appended    conditions:    cardiac,    vascular, 
hepatic,  neoplastic,  neurotic. 

In  the  first  place,  when  epigastric  pulsation  is  associated  with 
absence  of  the  apex-beat  in  its  normal  position,  the  possibility  of 
displacement  of  the  heart  should  be  confirmed  by  the  other  methods 
of  examination. 


INSPECTION  227 

Hypertrophy  and  dilation  of  the  right  ventricle  is  the  most  common 
cardiac  cause  of  epigastric  pulsation.  In  such  cases  the  impulse  is 
sgstolic  in  time.  The  left  ventricle  being  pushed  back  by  the  en- 
larged right  ventricle,  the  latter  communicates  its  pulsation  to  the 
lower  part  of  the  sternum,  and  to  the  left  lobe  of  the  liver  where  it 
lies  against  the  tissues  of  the  wall.  This  epigastric  pulsation  from 
dilated  right  ventricle  may  be  due  to  emphysema,  the  heart  being 
displaced  laterally  toward  the  breast-bone,  and  downward  upon  the 
diaphragm,  both  because  of  the  crowding  effect  of  the  dilated  lung 
and  of  the  increased  bulging  and  weight  of  its  own  enlargement,  the 
strain  upon  the  right  ventricle  in  emphysema,  on  account  of  the 
diminished  caliber  of  the  pulmonary  capillaries,  being  a  well-known 
pathologic  fact. 

In  hypertrophic  dilation  of  the  right  ventricle,  also,  secondary  to 
obstruction  or  incompetency  of  the  mitral  valve,  particularly  when  the 
tricuspid  orifice  leaks  because  of  the  extreme  dilation,  epigastric  pul- 
sation is  commonly  noticed.  This  is  augmented  by  a  pulsating  liver 
in  the  same  region,  the  systolic  impulse  of  the  regurgitation  through 
the  vena  cava  inferior  being  transmitted  also  through  the  engorged, 
swollen  liver  of  secondary  venous  congestion. 

Epigastric  pulsation  may  be  caused  by  aneurism  of  the  abdominal 
aorta,  the  expansile  throb  being  transmitted  through  the  left  lobe  of 
the  liver;  or,  if  the  aneurism  is  a  large,  sacculated  one,  the  pulsation 
may  be  conveyed  direct  to  the  surface  from  under  the  edge  of  this 
organ. 

Frequently,  in  neurotic  and  neurasthenic  individuals,  especially 
in  persons  with  comparatively  empty  abdomens,  with  thin,  emaciated, 
or  relaxed  (as  in  women  who  have  undergone  several  pregnancies) 
abdominal  walls,  an  exaggerated  aortic  impulse  in  the  epigastrium  is 
plainly  visible.  A  dynamic  pulsation  here  may  result,  also,  from 
hypertrophy  of  the  left  ventricle ;  from  cardiac  excitement,  in  anemia 
after  hemorrhage,  in  young,  hysteric  females,  and  during  the  climac- 
teric; in  old  persons  of  both  sexes  who  may  be  arteriofibrotic  or 
neurasthenic ;  and  from  the  reflex  effects  of  gastro-intestinal  digestive 
disorders,  movable  kidney,  etc. 

The  rhythm  of  the  aneurismal  and  functional  aortic  epigastric 
pulsations  is  an  instant  later  than  the  cardiac  impulse  (postsystolic). 

Any  tumor  overlying  the  aorta  in  the  epigastric  region  may  com- 
municate a  pulsation.  Thus,  a  pyloric  cancer  of  the  stomach,  a  pan- 
creatic or  hepatic  growth,  or  enlarged  lymph-glands  (tubercular) 
may  so  act,  except  when  the  patient  assumes  the  knee-chest  position 


228  PHYSICAL    DIAGNOSIS 

so  as  to  allow  the  tumor  to  fall  away  from  close  contact  with  the 
aorta. 

(e)  A  SYSTOLIC  RECESSION  of  the  epigastrium  often  accompanies 
chronic  adhesive  mediastino-pericarditis.  Here  the  movement  is  the 
reverse  of  the  ordinary  epigastric  pulsation — a  systolic  retraction  in- 
stead of  a  systolic  thrust  outward.  Sometimes  the  pericarditis  has 
been  so  extensive  that  the  combined  epigastric  and  lower  precordial 
pulsations  produce  an  undulatory  movement  which  may  be  confusing 
as  to  actual  time  of  occurrence  in  the  heart's  cycle  unless  they  are 
carefully  and  discriminatingly  compared  with  the  apex-beat,  the 
epigastric  and  intercostal  depressions  and  apical  impulse,  of  course, 
being  synchronous  in  systole. 

(3)  The  Apex-Beat. — In  studying  the  apex-beat  we  note  the  fol- 
lowing points  by  inspection:  (a)  The  position  of  the  impulse;  (b)  its 
extent;  (c)  its  strength;  (d)  its  rhythm.  The  strength  and  rhythm 
of  the  apical  impulse  may  be  roughly  estimated  by  the  eye,  but  need 
to  be  verified,  modified,  and  corrected  by  the  employment  of  palpation. 

These  factors  presuppose  the  visibility  as  well  as  tangibility  of  the 
apex-beat.  But  negative  evidence  as  to  the  pulsation  is  not  neces- 
sarily important  from  the  clinical  standpoint.  For  example,  in  very 
fat  and  muscular  people  the  absence  of  the  apex-beat  may  be  quite 
consistent  with  the  thick  parietes.  Again,  the  apex  may  happen  to 
thrust  behind  a  rib  in  a  perfectly  healthy  individual  with  a  variation 
of  the  anatomic  relations. 

(a)  POSITION  OF  THE  CARDIAC  IMPULSE. — While  the  normal  posi- 
tion of  the  cardiac  impulse  is  commonly  referred  to  as  the  apex-beat, 
it  is  actually  the  portion  of  the  heart  inside  the  true  anatomic  apex 
that  strikes  the  chest  wall.  However,  with  each  systole  or  contraction 
of  the  ventricles,  a  pulsation  representing  the  outermost  and  lower- 
most point  of  discernible  cardiac  movement  is  seen  normally  in  the 
fifth  interspace,  about  £  in.  inside  the  left  midclavicular  or  nipple 
line,  or  about  2£  to  3  in.  from  midsternum.  This  rhythmical  impulse 
is  confined  to  the  same  interspace,  its  lateral  extent  being  usually 
less  than  1  in.  The  character  of  the  pulsation  is  simply  a  gentle 
outward  movement  and  recession,  having  a  regular  rhythm  corre- 
sponding in  time  with  the  carotid  pulse. 

There  are  several  normal  variations  in  the  location  of  the  apex- 
beat.  Thus,  in  children  under  six  years  of  age  it  is  found  behind 
the  fifth  rib,  or  in  the  fourth  interspace;  in  the  very  old  it  pulsates 
in  the  sixth  interspace,  and  often  relatively  nearer  the  median  line 
than  in  the  young.  In  persons  with  short,  broad  thoraces,  also,  the 


INSPECTION  229 

cardiac  impulse  may  be  seen  in  the  fourth  interspace;  in  the  sixth  in 
those  with  long,  narrow  chests. 

Posture  affects  the  position  of  the  pulsation,  in  that  lying  on  the 
left  side  causes  it  to  be  seen  toward  the  axilla,  from  1  to  2  in.  to 
the  left.  The  recumbent  position  renders  the  beat  less  visible  than  the 
upright.  A  right-sided  shift  of  the  impulse,  although  not  so  marked, 
can  be  observed  when  the  individual  lies  upon  the  right  side. 

Respiratory  movement  modifies  the  position  of  the  apex-beat. 
During  a  full  inspiration  one  can  notice  the  impulse  lowered  an  in- 
terspace, even  producing  an  epigastric  pulsation;  with  the  expiratory 
rise  of  the  diaphragm  it  again  appears  above  the  sixth  rib,  and,  if 
the  effort  is  forced,  slightly  to  the  left  as  well. 

Distention  of  the  stomach  after  a  full  meal,  or  marked  flatulence, 
pregnancy  also,  may  cause  an  upward  movement  of  the  apex-beat. 

The  pathologic  causes  of  displacement  of  the  apex-beat  may  be 
summed  up  beforehand  as  cardiac.,  pericardia!,  or  external.  The 
direct  physical  causes  are  also  three,  in  themselves  the  result  of  the 
operation  of  the  preceding;  these  are  enlargement  of  the  heart,  dislo- 
cation of  the  heart,  and  deformity  of  the  chest.  Apical  displacements 
may  be  classified  conveniently  according  to  their  direction,  whether 
upward  or  downward,  to  the  right  or  left. 

(1)  Upward,  or  Upward  and  to  the  Left. — The  commonest  causes 
of  upward  displacement  of  the  apex-beat  are  intra-abdominal  enlarge- 
ments.    These  may  include  ascites  (abdominal  dropsy) ;  meteorism, 
as  from  peritonitis;  large  abdominal  tumors  of  various  kinds.     In 
these  conditions  the  apex  is  pushed  upward,  and  in  extreme  instances 
even  slightly  to  the  left  at  the  same  time.    In  the  absence  of  abdom- 
inal  distention,    an    apical   impulse    found   in   the   fourth   or    third 
interspace,  and  more  decidedly  to  the  left,  associated  with  general 
precordial  fulness,  is  due  to  pericardial  effusion.     Although  the  dis- 
location is  also  higher  than  from  abdominal  causes,  the  impulse  is, 
however,  less  distinctly  visible  because  of  the  interposed  liquid. 

An  upward  pulling  force  upon  the  heart  sometimes  occurs  from 
retraction  of  the  upper  lobe  of  the  left  lung  affected  with  fibroid 
phthisis.  In  deformity  of  the  thorax  produced  by  spinal  curvature, 
as  from  scoliosis  or  kyphosis,  we  may  find  the  apex-beat  in  the  fourth 
interspace. 

(2)  Downward,  or  Downward  and  to  the  Left. — Undoubtedly  the 
variety  of  displacement  most  frequently  encountered  is  that  of  hyper- 
trophy and  dilation  of  the  heart,  especially  of  the  left  ventricle — 
simultaneous  projection  down  and  to  the  left.     The  more  the  dis- 


230  PHYSICAL    DIAGNOSIS 

placement  downward  rather  than  to  the  left  the  greater  the  predomi- 
nance of  left  than  right  ventricular  enlargement,  and  of  hypertrophy 
over  dilation,  particularly  when  the  apical  impulse  is  apparently  for- 
cible and  circumscribed.  The  latter  may  be  detected  in  the  sixth 
interspace,  \  to  2  in.  outside  the  midclavicular  line,  or  in  exceptionally 
extreme  cases  as  far  as  the  eighth  interspace  and  in  the  midaxillary 
line. 

Simple  downward  dislocation  of  the  apex-beat  may  also  be  caused 
by  aneurism  of  the  aortic  arch,  pressure  of  mediastinal  solid  growths, 
thoracic  deformity,  marked  emphysema,  and  downward  traction  upon 
the  central  tendon  of  the  diaphragm  by  an  enlarged  liver;  sometimes 
by  moderate-sized  pleural  effusion  on  the  left  side,  or  a  pyopneumo- 
thorax — to  less  degree. 

(3)  To  the  Left. — Displacements  to  the  left  which  are  simultane- 
ously downward  or  upward  have  already  been  considered.    There  re- 
main those  which  are  practically  horizontal  in  direction.     Pleural 
conditions  which,  on  the  right  side,  push  the  heart  to  the  left,  or 
which,  on  the  left  side,  pull  it  to  the  left,  displace  the  apex-beat 
accordingly.    Thus,  a  pleuritic  effusion  or  pneumothorax  on  the  right 
side,  or  the  retraction  of  extensive  pleuritic  adhesions,  with  or  with- 
out chronic  fibroid  contraction  of  the  left  lung,  may  so  act  respectively. 
Another,  a  cardiac  cause,  'is  often  met  with  in  displacement  of  the 
apex-beat  merely  to  the  left,  namely,  hypertrophy  and  dilation  of 
the  right  ventricle ;  the  apex-beat  is  found  usually  in,  or  very  slightly 
outside,  the  mammillary  line,  in  the  fifth  interspace. 

(4)  To  the  Right. — Displacement  of  the  apex-beat  may  be  caused 
by  a  reversal  of  the  thoracic  conditions  mentioned  in  the  preceding 
paragraph.     Thus,   left-sided  pleural   effusion  or  pneumothorax,  or 
right-sided  adhesive  pleurisy  and  fibroid  contractions  of  the  lung  pro- 
duce such  displacement.     The  apex-beat  may  be  discovered  in  the 
epigastric  region,  in  the  angles  formed  by  the  ensiform  cartilage  and 
the  right  and  left  rib  borders.    In  extreme  cases  it  may  be  seen  in  the 
fourth  and  fifth  interspaces,  at  the  right  edge  of  the  sternum.     At 
the  same  time,  pulsation  may  be  noticed  as  far  to  the  right  as  the 
nipple  line,  but  this  is  referable  to  the  right  auricle  and  ventricle. 

Besides  these  affections,  deformity  of  the  chest  and  the  rare  and 
interesting  congenital  transposition  of  the  viscera  (situs  inversus) 
may  cause  a  dextrocardia.  In  the  latter  case  the  apex-beat  may  pul- 
sate on  the  right  side,  in  the  region  corresponding  to  its  normal 
location  upon  the  left. 

To  summarize,  the  principal  causes  of  displaced  apex-beat  are : 


INSPECTION  231 

Hypertrophy  and  dilation  of  the  heart,  down  and  to  the  left. 

Pericardial  effusion,  up  and  to  the  left. 

Chronic  pleural  and  phthisical  affections,  right  or  left. 

Emphysema,  down  and  sometimes  to  the  right. 

Pressure  of  subdiaphragmatic  conditions,  up  and  sometimes  to 
the  left. 

Pressure  of  aneurism  or  mediastinal  growths,  downward. 

(b)  ABNORMAL  EXTENT  OF  THE  APICAL  IMPULSE. — Alteration  in 
the  extent  of  the  apical  impulse  needs  to  be  discriminated  carefully 
from  an  impulse  near  by,  due  to  the  body  of  the  heart,  as  a  hyper- 
trophied  right  ventricle.  In  instances  of  the  former,  the  wavy,  cyclic, 
intercostal  recession  is  usually  found  extending  to  the  left  of  the 
actual  apical  thrust  (as  determined  better  by  palpation),  whereas,  in 
the  latter,  the  movement  is  confined  within  the  anatomical  limits 
of  the  heart;  indeed,  often  to  that  area  within  the  left  parasternal 
line  which  is  uncovered  by  lung.  In  marked  downward  and  outward 
displacement  of  the  apex,  not  infrequently  a  conjoined  precordial 
pulsation,  due  to  mass  and  apical  movement  of  the  heart,  may  be 
witnessed,  as  in  cases  of  greatly  enlarged  heart  (bovine  heart,  cor 
bo i- is),  the  result  of  prolonged  regurgitation  from  insufficiency  or 
leakage  of  the  aortic  valve. 

A  systolic  retraction  of  the  interspaces  around  the  apex-beat 
should  also  not  be  confounded  with  mere  increased  area  of  apical 
pulsation.  This  does  not  mean  that  the  apex  retracts  instead  of 
thrusts  forward  with  ventricular  contraction,  but  that  pericardial 
adhesions  exist  in  such  relation  to  the  apex  that  they  are  drawn  upon 
during  systole,  or  that  the  sinking  in  of  the  interspaces  is  due  to 
atmospheric  pressure  from  without,  induced  by  negative  pressure 
within  the  chest  because  of  the  vigorous  action  of  a  heart  in  hyper- 
trophic  dilation. 

The  extent  of  apical  impulse  may  be  abnormal  in  three  ways:  it 
may  be  increased,  diminished,  or  it  may  be  absent  totally. 

( 1 )  Increased  extent  of  apex-beat  is  almost  always  associated  with 
increased  force,  either  actual  or  relative,  and  with  displacement.  As 
increased  strength  of  beat  can  be  estimated  best  by  touch,  and  only 
inferred  by  sight,  its  relation  to  extent  will  necessarily  include  so 
much  as  can  be  gained  by  palpation  as  well  as  by  inspection,  if  partial 
statements  are  to  be  avoided. 

At  the  outset  it  may  be  set  down  that  an  impulse  in  the  fifth  inter- 
space more  than  1  in.  (2^  cm.)  in  breadth  is  abnormal.  A  slight  or 
moderate  increase  in  the  area  of  apical  pulsation,  in  the  fifth  or  sixth 


232  PHYSICAL    DIAGNOSIS 

interspace,  in  or  outside  the  left  midclavicular  line,  indicates  hyper- 
trophic  enlargement  of  the  heart,  especially  of  the  left  ventricle.  In 
more  marked  cases,  where  the  impulse  involves  two  or  three  inter- 
spaces outside  the  mammillary  line — the  fifth,  sixth,  and  seventh, 
for  instance — a  heaving  character  in  the  center,  shading  off  to  a  fine, 
wavy  tremor  near  the  periphery  of  the  movement,  points  to  the  massive 
predominance  of  hypertrophy  over  dilation,  although  both  are  in  com- 
bination. The  absence  of  a  central  thrust,  however,  and  a  still  more 
diffuse,  but  evidently  weaker,  impulse,  spreading  outward  rather  than 
downward,  with  slight  in-and-out  movement,  indicates  weakening  of 
the  heart  muscle  and  dilation  overcoming  hypertrophy,  at  least  tem- 
porarily. In  other  words,  the  latter  condition  exemplifies  the  fact 
that  the  extent  of  the  apex-beat  may  be  increased  without  the  strength 
being  increased,  and  that  the  greater  the  extent  the  weaker  is  the 
ventricular  muscle  likely  to  be,  since  it  rolls,  glides,  slaps,  or  flops 
against  the  chest  wall  in  flabby  fashion  in  dilation.  The  more  cir- 
cumscribed, although  yet  increased,  extent  of  apical  pulsation,  due 
to  predominant  hypertrophy,  on  the  contrary,  manifests  a  more  direct, 
concentrated,  plunging  thrust,  as  of  a  knuckle  of  a  hand  within  the 
chest. 

An  apex-beat  of  moderate  increase  of  extent  and  strength,  with- 
out dislocation,  is  apparent  in  a  group  of  disorders  more  or  less  func- 
tional in  nature.  Here  may  be  mentioned  nervous  palpitation,  as 
from  emotional  excitement;  exophthalmic  goiter  (Basedow's  or 
Graves's  disease),  and  poisoning  by  alcohol,  tobacco,  tea,  coffee, 
strychnin,  etc. 

A  relative  increase  in  extent  of  the  apex-beat  is  found  in  cases 
of  marked  retraction  of  the  lungs — anterior  border.  Here,  also,  there 
is  no  displacement  of  the  position  of  the  apical  impulse  unless  there 
are  at  the  same  time  extensive  and  firm  pleuritic  adhesions. 

A  wider  area  of  apex  pulsation  may  be  seen  as  the  result  of 
simple  dilation  of  the  heart  from  the  weakening  of  the  ventricular 
walls  affected  with  fatty  degeneration,  consequent  upon  severe  acute 
febrile  disease,  chronic  alcoholism,  and  the  like. 

It  should  be  borne  in  mind,  finally,  that  certain  normal  condi- 
tions may  give  rise  to  a  comparatively  increased  extent  of  apical 
pulsation.  Such  may  be — temporarily,  of  course — the  posture,  as  when 
the  individual  leans  forward ;  thin  chest  walls,  as  in  children ;  physical 
exertion  or  mental  excitement,  and  at  the  end  of  deep  expiratory 
efforts.  As,  after  violent  physical  exercise — athletic,  occupational,  or 
incidental  to  the  modern  rush  for  scheduled  trains,  and  so  on — a 


INSPECTION  233 

transient  acute  dilation  of  the  heart  may  ensue,  with  consequent  in- 
creased area  of  cardiac  and  apical  impulse,  with  slight  displacement 
of  the  latter  to  the  left,  a  proper  estimate  as  to  the  actual  condition 
of  the  heart  can  he  made  only  when  it  is  examined  at  such  a  length 
of  time  thereafter  as  to  exclude  their  possible  modifying  effects. 

('2)  Diminished  extent  or  absence  of  apex-beat  may  be  considered 
together.  They  may  or  may  not  be  accompanied  with  weakened 
impulse.  Provided  that  external  conditions  (to  be  mentioned  below) 
are  absent  as  factors,  a  diminished  or  just  apparent  apex  pulsation 
usually  indicates  weak  heart;  in  fact,  it  is  palpably  weakened. 

In  certain  normal  persons,  it  should  be  remembered,  nevertheless, 
the  apex-beat  may  be  barely  perceptible,  or  not  at  all  so.  This  may 
occur  especially  in  thick-chested  or  large-lunged  or  phlegmatic  people, 
in  the  dorsal  position,  and  sometimes  at  the  height  of  a  full  inspi- 
ration. 

Pathologically  it  is  diminished  or  lost  in  the  following: 

Overlapping  emphysematous  lung. 

Encroaching  pericardial  and  pleuritic  effusions. 

Myocardial  degeneration  and  dilation. 

Shock,  collapse,  hemorrhage,  acute  febrile  and  chronic  wasting 
disease. 

Pericardial  adhesions   (replaced  by  systolic  retraction). 

Sometimes  in  stenosis  of  the  aortic  valve  orifice. 

Inflammatory  or  edematous  tumefactions  of  the  skin  and  mural 
tissues. 

A  moderate  degree  of  emphysema  may  partially  conceal  the  apical 
activity  of  a  normal  heart;  a  marked  degree  may,  even  with  hyper- 
trophic  dilation  of  the  right  ventricle,  entirely  obliterate  any  impulse 
except  in  the  upper  part  of  the  epigastrium.  Absence  of  pulsation 
may  be  due,  also,  to  sufficient  downward  dislocation  of  the  apex  to 
cause  it  to  beat  just  behind  the  sixth  rib. 

Diminished  area  of  impulse  from  pleural  and  pericardial  effusions 
may  be  the  result  of  the  displacement  as  much  as  of  the  interposed 
liquid,  and  may  be  restored  for  the  time  by  having  the  patient  stoop 
forward. 

Weak  heart  may  be  diagnosticated  without  difficulty  whenever  a 
previously  increased  extent  of  apex-beat  in  the  fifth  and  sixth  inter- 
spaces, outside  the  nipple  line,  gives  place  to  diminished  extent,  and 
only  in  the  fifth  interspace. 

A  peculiar,  almost  paradoxical,  physical  sign  is  the  diminished 
apical  pulsation  of  certain  cases  of  aortic  stenosis,  since  the  strain 


234  PHYSICAL    DIAGNOSIS 

of  this  lesion  produces  decided  hypertrophy  of  the  left  ventricle.  Jt 
is  explained  hy  the  obstructive  delay  and  longer  duration  required 
by  the  ventricle  to  propel  the  blood  through  the  orifice,  so  that  the 
prompt  apical  thrust  which  would  ordinarily  occur  is  converted  into 
a  gradual,  labored,  prolonged  twist  of  light  contact  with  the  chest 
wall  comparatively. 

(c)  ABNORMAL  STRENGTH  OF  THE  CARDIAC  IMPULSE. — Increase, 
diminution,  or  absence  of  apical  pulsation  usually  corresponds  directly 
with  similar  qualities  of  extent,  although  not  invariably.   The  strength 
may  be  increased  without  an  increase  in  the  extent,  and,  vice  vcr.^i. 
the  extent  may  be  increased  and  the  strength  actually  diminished. 
As  intimated  before,  the  characteristics  of  apical  force  are  most  pre- 
cisely determined  by  palpation,  but  to  the  trained  observer  the  inter- 
costal movements  as  indices  of  myocardial  power  are  quite  significant. 
Obviously,  it  is  the  amplitude  or  excursion  of  movement  which  is 
suggestive:  the  more  circumscribed  and  bellied  the  rhythmical  thrust 
the  greater  the  firmness  of  cardiac  muscle;  the  more  flatly  wavy  and 
broadly  fibrillary  the  action  the  weaker  it  is.     Thus,  also,  a  firm, 
moderate-sized  hypertrophy  of  the  left  ventricle  exemplifies  the  state- 
ment of  increased  force  without  increased  extent  of  impulse,  while  the 
globularly  enlarged  heart  of  double-sided  dilation,  with  more  or  less 
fatty  degeneration,  exemplifies  the  converse. 

It  should  not  be  forgotten  that  many  individuals,  in  good  health 
and  with  sound  hearts,  manifest  no  apical  impulse  whatever.  Also, 
that  as  in  cases  of  increased  extent  of  pulsation,  so  increased  force 
may  be  due  to  purely  psychic  or  neurotic  causes,  as  in  hysteria,  Base- 
dow's  disease,  insidious  toxic  and  temperamental  conditions,  and  the 
like. 

(d)  ABNORMALITIES  OF  RHYTHM. — Apart  from  mere  increase  or 
decrease  in  the  frequency  (denominated,  respectively,  tachycardia  and 
bradycardia)  of  the  apex-beats,  the  normal  rhythm  or  regularity  may 
be  visibly  disturbed  as  regards  the  time  of  their  succession  and  the 
pauses  between  them,  their  fulness  and  force,  both  as  single  and 
variously  grouped  impulses. 

Cardiac  arJiythmia  may  thus  be  noticed  in  connection  with  ob- 
servation of  the  carotid  pulse.  The  heart-beats  may  visibly  alternate 
regularly — that  is,  every  other  beat  fails  to  appear,  or,  at  regular 
intervals,  say  every  third  or  seventh  or  eleventh  beat,  drops;  this 
constitutes  the  true  intermittent  heart,  and  may  be  normal  and 
peculiar  to  the  individual,  or  signify  a  transient  functional  disorder 
or  permanent  organic  valvular  or  myocardial  disease. 


INSPECTION  235 

Where  the  intervals  between  the  dropped  beats  do  not  occur  at 
regular  lengths,  and  where  the  beats  that  do  appear  succeed  each 
other  without  regularity  of  force,  frequency,  extent,  and  interval,  so 
that  the  cardiac  impulse  seems  to  be  tumultuous  and  incoordinate, 
reeling  and  floundering  like  a  drunken  man,  the  arhythmia  is  de- 
nominated simply  as  cardiac  irregularity.  This  phenomenon  is  al- 
ways indicative  of  grave  organic  heart  disease,  and  often  of  imminent 
and  speedy  dissolution. 

As  these  and  other  special  forms  of  arhythmia  may  be  detected 
and  estimated  with  greater  accuracy  by  palpation,  they  will  be  dis- 
cussed further  under  that  head. 

Rhythmic  lateral  displacement  of  the  heart  is  not  infrequently  a 
valuable  sign  of  unilateral  pleuritic  exudate,  as  first  pointed  out  by 
C.  L.  Greene.  It  is  most  marked  in  moderate  effusions;  the  heart 
approaches  the  affected  side  in  inspiration,  and  moves  outward  during 
expiration;  the  extent  of  the  movement  is-  about  2  in.,  and  it  may 
be  detected  by  fluorscopic  examination,  auscultatory  percussion,  and 
ordinary  deep  percussion,  as  well  as  by  inspection  of  the  apex-beat. 


CHAPTER    X 
PALPATION 

Palpation  determines  the  physical  signs  discoverable  by  inspection, 
and  so  confirms  its  results;  checks  or  modifies  its  results  as  regards 
certain  dubious  signs  that  may  seem  evident,  but  are  really  deceiving 
to  the  eye,  and  contributes  certain  other  signs  which  cannot  be  con- 
sidered visible.  While  supplementary  to  inspection,  therefore,  in  the 
order  of  investigation  of  the  cardiac  phenomena  in  the  precordium 
and  its  vicinity,  palpation  is  so  necessary  to  render  complete  and  in- 
telligible these  phenomena  that  practically  these  two  methods  are  most 
often  employed  simultaneously,  the  hand  closely  following  the  eye  in 
nearly  every  detail  before  passing  to  the  next  physical  sign,  which 
receives  the  same  conjoint  study,  and  so  on. 

Thus  palpation  enlarges  our  knowledge  as  to  the  form  of  the 
precordial  space;  as  to  abnormal  pulsations,  even  detecting  those 
which  are  too  feeble  to  be  noticed  by  the  eye;  and  determines  the 
situation  of  the  (anatomic)  apical  impulse,  its  force,  extent,  and 
character  and  rhythm,  as  well  as  the  condition  of  the  superficial  tissue-; 
and  intercostal  spaces,  especially  in  relation  to  the  signs  of  edeimv 
and  pus  accumulations.  In  addition  to  these,  palpation  discovers  the 
peculiar  vibrations  known  as  thrills,,  connected  with  organic  valvular 
defects,  and  the  presence  of  pericardial  friction  fremitus. 

The  visible  and  palpable  phenomena  of  the  arteries  and  veins  are 
intimately  connected  with  those  of  the  heart,  physiologically,  patho- 
logically, and  clinically,  and  all  must  be  considered  together  in  phys- 
ical diagnosis.  Nevertheless,  the  arterial  and  venous  signs  will  be 
dealt  with  in  a  subsequent  chapter,  so  as  to  avoid  confusion  by  reason 
of  the  extra  facts  superadded  to  those  of  strictly  cardiac  origin. 

SHAPE    OF   THE    PRECORDIUM 

Although  primarily  and  satisfactorily  perceived  by  inspection,  any 
undue  general  or  local  precordial  prominence  or  depression  may  be 
more  fully  investigated  by  palpation.    At  the  same  time,  some  knowl- 
236 


PALPATION  237 

edge  of  the  character  and  cause  of  the  altered  form  may  be  derived 
by  touch;  as  to  whether  the  increased  size,  for  example,  is  due  to 
an  exostosis  or  bony  costal  growth,  an  old  fracture  callus,  a  localized 
inflammatory  edema,  excessive  muscular  development,  or  to  hyper- 
trophy of  the  heart  or  pericardial  effusion  on  account  of  increased 
sensation  of  resistance  in  the  intercostal  spaces  in  or  beyond  the  lung- 
exposed  area.  Intercostal  depressions  are  likewise  recognizable  as 
compared  to  the  normal  fulness  and  firmness  of  the  corresponding 
spaces  on  the  opposite  side. 

ABNORMAL    PULSATIONS 

Some  that  are  not  visible  are  palpable,  and  may  seem  to  be  extra 
apex-beats  of  feeble  force,  when  not  above  the  fourth  rib.  At  the 
base  of  the  heart,  the  pathologic  pulsations  noted  under  inspection 
are  particularly  amenable  to  palpation.  Thus  the  aneurismal  expan- 
sile pulsations,  systolic  in  time,  over  the  aortic  arch  may  be  felt ;  also 
the  dynamic  pulsations  of  the  pulmonary  artery  and  the  auricles, 
either  from  exposure  by  retracted  lung  or  because  of  hypertrophied 
and  dilated  right  ventricle,  and  left  auricle  especially.  The  dias- 
tol'ic  shock  accompanying  closure  of  the  aortic  valve  in  aortic  aneurism 
may  also  be  felt  in  this  region. 

Below  the  fourth  rib,  the  epigastric  pulsation  due  to  hypertrophied 
right  ventricle,  or  to  pulsating  liver  (venous),  or  the  heave  over  the 
body  of  this  portion  of  the  heart,  between  the  sternal  margin  and 
the  left  parasternal  line,  are  quite  perceptible  to  touch. 

It  should  be  borne  in  mind  just  here  that  the  hand  of  the  ex- 
aminer not  infrequently  detects  a  slight,  diffuse  shock  over  the  middle 
of  the  precordium,  even  in  health,  and  terminates  in  the  fifth  inter- 
space in  the  more  circumscribed,  plunging  throb  of  the  apex-beat. 
This  is  more  distinctly  felt,  of  course,  in  those  with  thin  chest  walls, 
and  especially  when  leaning  slightly  forward.  In  such  persons,  in 
such  a  posture,  the  hand  placed  in  the  third  and  fourth  interspaces 
may  also  perceive  a  normal  sharp  jerk  or  shock  during  diastole,  due 
to  the  closure  of  the  two  semilunar  valves — aortic  and  pulmonary. 

"When  the  whole  heart  is  dilated  and  hypertrophied,  a  more  or 
less  violent  shock  may  be  felt  over  the  entire  cardiac  area,  and  when 
the  size  of  the  heart  is  considerable,  this  shock  may  be  double — the 
first  forcible  and  systolic,  the  second  less  forcible  and  diastolic,  the 
result  of  the  rebound  of  the  enlarged  heart  from  the  posterior  tho- 
racic walls"  (Balfour). 


238  PHYSICAL    DIAGNOSIS 


THE   APEX-BEAT 

Position  of  the  Impulse. — The  method  is  important  in  ascertain- 
ing this  point.  A  general  or  approximate  knowledge  as  to  the  posi- 
tion of  the  apex-beat  should  be  obtained  first  by  applying  the  right 
hand  lightly  and  evenly  just  below  the  left  nipple,  the  examiner 
standing  to  the  patient's  right.  In  this  way  one  gets  a  palpable 
survey  of  the  region  in  which  a  displaced  apex  may  possibly  be  found. 
At  that  portion  of  the  hand  under  which  the  most  distinct  impulse 
is  felt — as  under  the  second  knuckle,  for  example — the  apex  may 
roughly  be  estimated  to  be.  Marking  the  spot  by  the  eye,  on  removal 
of  the  hand  the  precise  apical  pulsation  may  then  be  localized  by 
noting  its  point  of  maximum  throb  with  the  tips  of  one  or  two  fingers. 
It  is  assumed  that  the  patient  is  in  the  standing,  sitting,  or  semi- 
reclining  posture. 

In  the  normal  chest,  the  apical  as  well  as  the  general  cardiac 
impulse  is  better  appreciated  in  those  with  thin  walls,  at  the  end 
of  expiration,  while  the  lungs  are  retracted  as  much  as  possible,  and 
while  the  body  leans  forward.  In  cases  of  diffuse  apex-beat,  where, 
indeed,  fine  surface  vibrations  may  be  seen  extending  over  an  area 
wider  than  they  are  perceptible  to  the  touch,  accurate  determination 
of  the  apical  position  may  be  baffled.  But  wherever  within  such  a 
region  the  finger  of  the  diagnostician  is  met  apparently  by  another 
inside  the  chest  rhythmically  poking  outward  against  it — in  other 
words,  at  the  most  circumscribed  point  of  most  marked  impulse — 
there  the  apex  may  be  considered  to  functionate. 

Palpation  corroborates  with  exactness  the  displacements  of  the 
apex-beat  due  to  the  respective  causes  given  under  inspection.  Since 
the  apical  impulse  corresponds  with  the  cardiac  systole,  and  occurs 
a  fraction  of  a  second  before  the  radial  pulse,  its  importance  as  a 
standard  for  the  timing  of  abnormal  pulsations  is  obvious.  It  should 
be  recollected,  also,  that  the  extreme  left  border  of  the  apical  impulse 
in  the  fifth  interspace  extends  nearly  an  inch  beyond  the  actual  maxi- 
mum throb  of  the  apex. 

Extent  and  Strength  of  Impulse. — The  relative  value  in  accuracy 
of  palpation  and  inspection  varies  in  respect  to  the  width  or  extent 
of  the  apical  pulsation;  but,  as  intimated  before,  while  the  force  of 
the  apex -beat  may  only  be  inferred  by  inspection,  its  more  precise 
estimation  may  be  determined  directly  by  palpation.  As  to  the  first 
point,  then,  in  some  cases  the  extent  may  be  seen  more  widely  than 


PALPATION  239 

felt,  while  in  others  the  area  of  impulse  is  tangible  a  little  beyond 
any  visible  vibrations. 

Before  considering  the  principal  pathologic  indications  of  altera- 
tions of  the  strength  and  extent  of  the  apical  cardiac  impulse,  two 
things  preliminary  should  be  borne  in  mind,  namely,  the  relation  of 
these  combined  factors  and  their  normal  variations.  In  regard  to  the 
former,  although  to  a  certain  degree  increased  force  of  apex-beat  is 
accompanied  with  an  increase  of  extent,  this  is  not  necessarily  in- 
versely so.  Thus,  most  often  a  moderate  increase  of  the  extent  usually 
means  a  predominantly  hypertrophied  heart;  on  the  other  hand,  a 
marked  increase  in  the  area  of  pulsation  is  commonly  palpable  with 
marked  weakness  of  the  heart  muscle — a  predominance  of  dilation 
and  flabbiness,  with  a  rounded  and  enlarged  apex. 

In  regard  to  the  other  point,  it  is  important  to  remember  that 
age,  poxtiin1,  rcxjiiration.  diet,  physical  exercise,  and  emotional  ex- 
citement may  influence  the  force  as  well  as  partly  the  position  of  the 
apex-beat.  Thus,  in  childhood  the  force  of  the  beat  is  relatively 
greater,  on  account  of  the  thin,  flexible  chest  wall  and  the  condition 
of  the  lungs.  In  old  age  it  may  be  relatively  weak  because  of  thick 
chest  walls  and  senile  hypertrophy  of  the  lungs,  or  stronger  because 
of  senile  hypertrophy  of  the  heart.  Again,  in  the  normal  state,  if  the 
individual  inclines  his  body  slightly  forward  and  to  the  left,  the 
apex-beat  becomes  temporarily  stronger,  while  if  to  the  right,  it  grows 
faint  or  disappears,  only  the  right  ventricular  impulse  being  felt  near 
the  sternum  in  the  fourth  and  fifth  interspaces,  or  in  the  upper  epi- 
gastric region.  At  the  end  of  expiration,  particularly  when  the  breath 
is  held  for  a  moment,  the  apical  force  is  increased;  also  after  a  full, 
stimulating  meal.  Finally,  the  force  and  extent  are  increased  during 
physiologically  increased  cardiac  activity  from  more  or  less  bodily 
exertion  and  psychic  stress. 

Palpable  exaggeration  of  apical  force  is  noted  in  connection  with 
the  abuse  of  tea,  coffee,  tobacco,  alcohol,  alcoholic  and  narcotic  pro- 
prietary and  "  patent "  medicines  and  other  drugs  used  by  habitues. 
In  the  early  stages  of  acute  fevers,  in  nervous  palpitation,  so-called, 
hysteria  and  other  neuroses,  and  associated  at  times  with  the  tachy- 
cardia of  exophthalmic  goiter,  the  same  physical  sign  may  be 
perceived. 

The  commonest  abnormality  is  a  forcible  apex-beat  of  moderate 
increase  in  area  felt  over  a  manifestly  displaced  apex  in  the  fifth 
interspace,  a  trifle  outside  the  nipple  line,  or  in  the  sixth  and  fifth  in- 
terspaces, perhaps,  as  much  as  1  or  1|  in.  outside.  This  is  always  a 


240  PHYSICAL    DIAGNOSIS 

clear  indication  of  enlarged  heart  with  hypertrophicd  walls.  The 
greater  the  amount  of  associated  impulse  over  the  body  of  the  heart, 
and  of  epigastric  pulsation,  the  greater  the  size  and  massiveness  of 
the  ventricles. 

The  force  and  extent  of  the  apex-beat  are  increased  also  in  the 
earlier  stages  of  acute  endocarditis  and  pericarditis,  by  pericardial 
adhesions,  and  by  such  extrinsic  causes  as  chronic  nephritis  (hyper- 
trophy of  left  ventricle),  retraction  of  lung,  or  consolidation  of  lung 
overlapping  the  apex. 

WEAKENING  or  LESSENING  of  the  apex-beat  is,  as  pointed  out  un- 
der inspection,  found  in  persons  in  health,  although  not  infrequently 
an  apex-beat  that  is  invisible  may  be  at  least  faintly  palpable.  In 
twofold  generality,  the  causes  of  diminished  strength  gf  apical  impylse 
are  either  those  which  weaken  the  myocardium  or  those  which  inter- 
pose some  adventitious  substance  between  the  heart  and  the  chest 
wall.  These  causes  were  detailed  in  treating  of  inspection.  Suffice 
it  here  simply  to  mention,  under  the  first  of  the  preceding  conditions, 
myocarditis  and  fatty  degeneration  due  to  endocarditis  and  pericar- 
ditis, or  to  prolonged  and  exhausting  infectious  fevers,  anemias, 
cachexias,  obesity,  inanition,  etc.  Under  the  second  category  are 
to  be  placed  emphysema  and  pleural  and  pericardial  effusions. 

Whenever  fatness  or  undue  thickness  of  the  chest  wall  or  emphy- 
sema of  the  lung  can  be  excluded,  and  the  signs  of  pericardial  or 
pleural  effusion  are  absent,  diminished  force  of  the  apex-beat  gener- 
ally signifies  cardiac  weakness. 

TOTAL  IMPEBCEPTIBILITY  to  touch,  of  the  apex-beat,  may,  in  some 
cases  of  cardiac  or  adjacent  disease,  be  noted  as  having  the  usual 
problematic  value  of  negative  evidence.  That  is,  in  a  stout  person, 
for  example,  it  may  have  been  a  characteristic  before  the  onset  of 
the  malady;  it  may  be  simply  a  manifestation  of  marked  general 
weakness  from  a  protracted,  prostrating  illness;  it  may  have  the 
relative  value  indicative  of  emphysematous  or  pleuritic  interference 
rather  than  any  direct  cardiac  or  pericarditic  affection.  Absent 
apical  impulse  due  to  myocardial  troubles  may  result  from  an  exag- 
geration of  those  conditions,  causing  lessened  or  weakened  impulse. 
Not  infrequently  a  previously  imperceptible  pulsation  may  become 
palpable  after  a  little  exertion  on  the  part  of  the  patient,  such  as 
sitting  up  in  bed  or,  if  his  condition  permits,  walking  to  and  fro 
rapidly  for  a  dozen  or  twenty  paces,  or  taking  several  deep,  forcible 
breaths.  The  administration  for  a  few  days  of  cardiac  stimulants 
may  also  elicit  a  palpable  apex-beat. 


PALPATIOX  241 

It  is  well  to  repeat  what  was  said  under  inspection  concerning 
absence  of  the  apex-beat  in  stenosis  of  the  commencement  of  the  aorta, 
even  where  there  are  percutory  and  auscultatory  signs  of  hypertrophy 
of  the  left  ventricle,  the  slow  ventricular  contraction  from  difficulty 
in  emptying  itself  aborting  the  real  apical  thrust. 

Systolic  Recession. — The  apex-beat  is  often  wanting  because  re- 
placed by  this  condition,  which  may  be  even  more  perceptible  to  the 
hand  than  to  vision.  Systolic  retraction  is  seldom  limited  to  the 
apical  region,  however,  but  is  usually  but  a  part  of  the  rhythmical 
drawing  in  of  the  whole  lower  portion  of  the  heart  area  found  in 
cases  of  pericardial  or  mediastinal  adhesions.  In  a  fair  percentage 
of  instances  this  sign  is  associated  with  that  of  Broadbent,  namely,  a 
similar  rhythmical  recession  in  the  eleventh  or  twelfth  left  interspace 
posteriorly.  According  to  Gibson,  an  important  accompanying  sign 
of  adherent  pericardium  is  a  distinct  impulse  of  "  rebound  or  recoil " 
felt  along  with  the  diastole. 

Rhythm  of  the  Apical  Impulse. — By  palpation  this  may  be  deter- 
mined with  much  greater  accuracy  than  by  inspection.  This  pertains 
to  all  forms  of  intermittency  and  irregularity,  as  pointed  out  under 
the  latter  heading.  It  should  be  remembered  that  inequalities  of 
frequency,  interval,  size,  and  strength  of  the  apex-beats  are  significant 
phenomena  of  failure  of  the  cardiac  muscle  and  function. 

Groupings  of  the  heart-beats  in  twos  and  threes  may  occur,  cor- 
responding to  the  analogous  bigeminal  and  trigeminal  pulse. 

Doubling  of  the  Apex-Beat. — By  this  is  understood  two  pulsations 
of  the  apex  to  a  single  carotid  pulse-beat,  or  radial.  The  phenome- 
non was  attributed  by  Skoda,  Leyden,  and  others  to  a  hemisystole ; 
that  is,  to  an  action  of  the  heart  in  which  the  ventricles  do  not  con- 
tract simultaneously.  A  more  rational  explanation  of  doubled  apex- 
beat  is  the  occurrence  of  alternating  weak  contractions  of  the  heart, 
corresponding  to  alternating  pulse  (pulsu-s  alternans),  every  other 
ventricular  systole  being  too  feeble  to  transmit  a  pulse-wave  as  far 
as  the  radial  artery,  but  not  so  feeble  as  not  to  be  palpable  itself.  In- 
deed, however,  the  alternating  weak  apical  impulse  is  seldom  so  feeble 
that  at  least  a  weak  pulsation  over  the  carotid  artery  may  not  be  felt. 

ADVENTITIOUS    PALPABLE   SIGNS 

Cardiac  Thrills. — A   thrill  is  a  short,  trembling  sensation,  felt 
usually  in  the  region  of  the  apex.     It  is  of  endocardial  origin,  the 
result  of  obstructive  or  incompetent  orificial  or  valvular  lesions,  or, 
18 


242  PHYSICAL   DIAGNOSIS 

when  felt  at  the  base  of  the  heart  on  the  left  side,  may  be  due  to 
the  diminished  plasticity  of  anemic  blood.  In  any  case,  thrill  is 
produced  only  at  the  time  the  blood  is  passing  through  the  orifice 
affected;  during  systole,  through  the  arterial — aortic  and  pulmonary 
— openings,  and  through  the  auraculoventricular — mitral  and  tricus- 
pid — openings  during  diastole.  The  feel  of  a  thrill  simulating  that 
of  the  purring  of  a  cat  led  Laennec  to  call  it  fremissement  catairc, 
and  the  Germans,  katzenschniirren.  The  sensation  communicated  to 
the  fingers  may  also  be  considered  analogous  to  the  tremor  of  a 
roughly  working  steam  feed-pump,  or  marine  engine. 

As  thrills  usually  coincide  with  the  valvular  murmurs  heard  on 
auscultation,  a  careful  recognition  of  them  may  serve  as  preliminary 
or  presumptive  clues  to  the  nature  of  the  pathologic  difficulty,  whether 
an  insufficiency  due  to  degenerated  valves,  or  a  stenosis  of  the  orifice, 
which  causes  the  whirling  eddies  of  the  blood  stream,  whose  vibrations 
become  thus  palpable  and  audible  on  the  chest  surface.  As  will  be 
shown  later,  also,  in  treating  of  auscultation,  where  the  murmurs  have 
diagnostic  significance  according  to  certain  points,  so,  in  regard  to 
thrills,  it  is  necessary,  first,  to  locate  them;  secondly,  to  time  them — 
that  is,  to  determine  their  rhythm;  thirdly,  to  circumscribe  them — 
that  is,  note  their  extent  or  area  of  diffusion.  Most  thrills  occur  at 
the  selective  mitral  region,  near  the  apex.  Those  most  distinct  are 
presystolic  in  rhythm,  and  the  same  involve  a  larger  area  of  vibration 
than  the  systolic  or  diastolic.  The  principal  thrills  are  as  follows : 

MITRAL  PRESYSTOLIC  THRILL. — At  the  apex,  the  commonest  dis- 
tinctive thrill  is  that  which  occurs  just  before  the  systolic  impulse, 
and  terminates  abruptly  at  the  height  of  impact  of  the  latter.  It 
has  a  rough,  hesitating,  purring,  or  jogging  character.  It  is  usually 
limited  to  a  moderately  diffuse  area,  rather  more  inside  than  outside 
the  apex-beat,  which  is  seldom  displaced  beyond  the  nipple  line.  In 
some  exceptional  cases  the  thrill  occupies  the  greater  part  of  diastole, 
commencing  feebly,  and  reaching  its  maximum  intensity  immediately 
preceding  the  apical  thrust — diastolic  thrill  of  mitral  stenosis.  As 
indicated  by  the  last  word,  this  apical  thrill  signifies  a  narrowing 
at  the  mitral  orifice,  since  the  blood  passes  through  that  orifice  during 
diastole,  augmented  at  the  end  by  the  contraction  of  the  left  auricle, 
which  thus  develops  the  difficulty  at  that  time  (presystole)  in  causing 
the  thrill. 

MITRAL  SYSTOLIC  THRILL. — This  is  generally  a  soft,  short,  indis- 
tinct tremor,  felt  just  over  the  apex,  which  may  be  outside  the  nipple 
line  in  the  fifth  or  sixth  interspace.  It  coincides  with  the  lifting 


PALPATION  243 

and  receding  of  the  apical  impulse.  It  is  due  to  leakage  or  insuffi- 
ciency at  the  mitral  orifice.  This  valve  should  be  closed  during 
systole;  consequently  the  systolic  thrill  means  a  regurgitating  whirl- 
ing of  opposing  currents  of  blood  permitted  by  the  incompetency  at 
that  time. 

Very  rarely,  delicate  thrills  may  be  palpable  over  the  apical  region 
which  are  transmitted  downward  from  the  aortic  area,  especially  a 
systolic  one  due  to  aortic  obstruction,  and  sometimes  a  diastolic  one 
due  to  aortic  regurgitation. 

AORTIC  SYSTOLIC  THRILL. — This  is  most  distinctly  felt  in  the 
second  right  intercostal  space,  and  occurs  next  in  frequency  to  the 
mitral  presystolic.  It  is  often  perceptible  over  the  carotid,  and  along 
the  right  and  left  margins  of  the  sternum,  as  far  down  as  the  ensi- 
form,  perhaps.  As  the  aortic  valve  should  be  open  during  systole,  a 
disturbance  in  the  onflow  of  blood  must  be  due  to  obstructive  thick- 
ening or  atheromatous  stenosis  of  the  orifice  to  produce  a  systolic 
thrill  at  its  maximum  in  that  location. 

AORTIC  DIASTOLIC  THRILL. — This  has  its  point  of  greatest  in- 
tensity, which  is  rarely  marked,  however,  also  in  the  second  right 
interspace.  It  is  a  soft,  continuous  thrill,  felt  along  the  sternum, 
toward  the  apex,  during  most  of  the  diastolic  time;  even  over  most 
of  the  precordium  in  aggravated  cases. 

The  thrill  of  aortic  stenosis  must  not  be  confounded  with  that 
due  to  aneurism  of  the  aortic  arch.  Here  the  peculiar  whizzing 
sensation  may  be  discovered  between  the  suprasternal  notch  to  the 
level  of  the  fourth  rib  on  either  side  of  the  sternum,  and  is  usually 
accompanied  with  a  pulsating  swelling. 

THRILLS  DUE  TO  TRICUSPID  AND  PULMONARY  VALVE  LESIONS. — 
A  systolic  thrill  felt  over  the  lower  part  of  the  sternum  is  much  more 
likely  to  be  transmitted  from  the  aortic  orifice,  and  therefore,  as  the 
rare  result  of  tric-uspid  regurgitation,  can  be  assuredly  diagnosed 
only  when  associated  with  synchronous  pulsation  of  the  jugular 
veins. 

The  other  three  forms  of  right-sided  valvular  disease  analogous 
to  the  left-sided  lesions  referred  to,  although  possibly  attended  with 
thrills,  occur  so  rarely  that  they  may  practically  be  unheeded  here. 
This  is  especially  true  of  tricuspid  stenosis  (diastolic,  presystolic) 
and  pulmonary  regurgitation  (diastolic).  In  the  second  or  third  left 
interspace,  a  systolic  thrill  may  be  due  to  the  congenital  pulmonary 
stenosis,  or  to  fibroid  phthisis  with  retraction  of  the  left  lung  at  its 
anterior  border,  accompanied  with  exaggerated  activity  of  the  right 


244  PHYSICAL    DIAGNOSIS 

ventricle.  A  little  higher,  in  the  first  interspace,  slight  thrill  may  be 
felt  in  exophthalmic  goiter. 

Thrill  in  the  second  left  intercostal  space  may  be  quite  pronounced 
in  another  form  of  rare  congenital  heart  disease,  namely,  permanent 
patency  of  the  ductus  artcriosus.  This  thrill  lasts  throughout  systole 
and  a  part  of  diastole,  owing  to  the  fact  that  "  the  blood  stream 
flows  from  the  higher  pressure  of  the  aorta  to  the  lower  pressure  of 
the  pulmonary  artery.  It  must  therefore  generally  occur  after  the 
aortic  pressure  has  reached  a  certain  level,  and  will  persist  until  it 
has  fallen,  at  least  to  some  extent"  (Gibson). 

Attempts  have  been  made  to  obtain  cardiographic  tracings  of 
thrills,  but  unsuccessfully.  In  cases  where  the  cardiogram  recorded 
any  variation  at  all,  it  was  due  to  interrupted  or  irregular  heart  action, 
and  not  to  thrill,  although  that  was  easily  palpable  to  light  pressure 
of  the  fingers. 

Pericardial  Friction  Fremitus. — This  is  a  superficial  rubbing  sen- 
sation similar  to  that  felt  over  a  patch  of  dry  pleuritis,  and  usually 
decidedly  rougher  than  an  endocardial  thrill.  I  have  described  it  to 
students  as  simulated  by  lightly  passing  a  piece  of  emery  paper  across 
the  hand.  It  is  a  rhythmic  to-and-fro  sensation — systolic  and  dias- 
tolic — felt  over  the  body  of  the  heart,  and  obviously  signifies  a  dry, 
plastic,  fibrinous  pericarditis. 

Fluctuation. — In  instances  of  large,  copious  liquid  effusions  into 
the  pericardial  sac,  waves  of  fluctuation  may  sometimes  be  felt  in  the 
lower  precordial  interspaces. 

Valve  Shocks. — These  are  palpable  in  certain  cases  because  of  the 
exaggerated  intensity  of  closure  of  the  semilunar  and  auriculoven- 
tricular  sets  of  valves.  Conditions  affecting  the  former  are  distinctly 
felt  in  the  upper  precordium  as  diastolic  shocks,  and  those  of  the 
latter  producing  systolic  shocks,  usually  in  the  fourth  intercostal 
space  near  the  sternum — left  edge — but  only  in  persons  with  thin 
chest  walls  in  both  cases.  Increased  tension  in  the  aorta  or  pulmo- 
nary artery,  from  left  ventricular  hypertrophy  or  increased  peripheral 
resistance  in  the  systemic  arteries,  or  right  ventricular  hypertrophy 
and  increased  resistance  in  the  pulmonary  circulation,  are  indicated, 
respectively.  Over  the  lower  half  of  the  precordium  the  systolic  shock 
points  to  hypertrophic  dilation  of  the  ventricles. 


CHAPTER    XI 
PERCUSSION 

BY  this  method  of  examination  we  may  determine  the  size,  shape, 
and  location  of  the  heart.  These  objects  are  attained  essentially  by 
delimiting  the  heart  from  the  other  thoracic,  and  from  the  abdominal, 
organs  which  border  upon  it.  The  fact  that  the  heart  is  an  airless 
organ  makes  it  possible  to  outline  its  relations  only  with  those  adja- 
cent structures  which  are  more  or  less  air-containing,  and  thus,  on 
percussion,  give  rise  to  different  qualities,  intensities,  etc.,  of  sound. 

As  the  heart  is  surrounded  and  partially  overlapped  on  three  sides 
by  the  lungs,  the  determination  of  the  heart -lung  boundary  is  by  all 
odds  practically  the  most  important.  The  percutory  relations  of  heart 
to  stomach  and  to  liver  are  seldom  available  for  diagnostic  purposes. 
Obviously,  in  outlining  that  portion  of  the  heart  uncovered  by  lung, 
one  at  the  same  time  determines  any  extension  or  retraction  of  the 
anterior  border  of  the  left  lung. 

Percussion  of  the  precordium  develops  the  presence  of  two  areas 
or  varieties  of  dulness,  according  as  we  percuss  directly  over  that 
small  portion  of  the  heart  uncovered  by  lung  and  in  close  contact 
with  the  chest  wall,  or  over  a  surrounding  zone  of  the  heart  over- 
lapped by  a  portion  of  the  anterior  lung  margins.  The  first  is  known 
as  the  area  of  absolute  or  superficial  cardiac  dulness;  the  second,  as 
the  area  of  relative  or  deep  cardiac  dulness.  With  good  reason,  so  as 
to  avoid  confusion  and  reversal  of  terms — a  common  error  and  diffi- 
culty among  medical  students — Butler  prefers  the  following  desig- 
nations :  the  exposed  dulness,  the  covered  dulness,  and,  both  together, 
the  entire  dulness  of  the  heart. 

PERCUSSION    OF    THE    NORMAL    HEART 

The  aim  being  principally,  in  clinical  work,  to  ascertain  the  size 
of  the  heart  in  two  dimensions,  as  projected  in  an  approximate  plane 
upon  the  chest  surface,  and  to  determine  the  cardiac  relations  to  the 

245 


246  PHYSICAL    DIAGNOSIS 

overlying  lung  especially,  as  well  as  the  presence  or  absence  of  any 
abnormal  structure  in  contact  with  the  heart  and  great  vessels,  the 
percussion  of  the  normal  heart  areas  of  absolute  and  relative  dulness 
needs  first  to  be  studied  before  the  pathologic  deviations  can  be  esti- 
mated fairly. 

As  in  the  percussion  of  pulmonary  conditions,  so  here  much  de- 
pends upon  the  uniformity  and  dexterity  with  which  the  particular 
method  is  applied,  the  accuracy  and  reliability  of  the  technic,  and 
the  acuteness  of  perception  of  the  physician. 

Methods  of  Percussion. — There  are  "three  methods  applicable  to 
the  determination  of  the  areas  of  cardiac  dulness:  (1)  Ordinary 
pleximetric  percussion,  with  the  fingers  alone — at  once  the  most  serv- 
iceable and  satisfactory — or  with  an  artificial  pleximeter;  (2)  pal- 
patory  percussion,  and  (3)  auscultatory  percussion.  All  three 
methods  have  distinctive  value;  the  first  has  the  advantage  of  direct- 
ness, ordinarily  sufficient  accuracy,  and  practical  convenience;  the 
finger  method  enables  the  examiner  also  to  note  the  sense  of  resist- 
ance. This  latter  is,  on  the  other  hand,  the  sole  basis  of  the  palpatory 
method,  without  the  sound  effects  and  differences,  and,  with  the 
auscultatory  method,  constitutes  an  important  addition  to  the  more 
precise  outlining  of  the  heart  requisite  in  cases  needing  special  study 
because  of  complicating  or  obscuring  physical  conditions. 

In  the  practise  of  ordinary  finger  percussion  two  facts  should  be 
borne  in  mind,  namely,  that  only  light  strokes  must  be  employed  to 
detect  the  boundaries  of  the  area  of  superficial  or  absolute  dulness, 
strong,  heavy  strokes  being  necessary  to  elicit  Ihe  deep  or  relative 
dulness.  Before  describing  the  technical  details  of  the  various  meth- 
ods of  percussion,  the  student  should  be  acquainted  with  the  normal 
extent,  shape,  and  limits  of  these  two  cardiac  areas. 

The  superficial  or  exposed  cardiac  dulness  is  roughly  quadrilateral 
in  shape,  or  sometimes  triangular.  Its  upper  and  outer  boundaries 
correspond  to  the  anterior  border  of  the  left  lung.  Superiorly,  there- 
fore, the  absolutely  dull  or  flat  sound  begins  at  the  upper  edge  of  the 
fourth  left  costal  cartilage  in  the  parastemal. line.  Thence  the  dulness 
continues  vertically  downward  to  the  upper  border  of  the  sixth  rib. 
The  determination  of  this  inferior  boundary  of  the  superficial  dulness 
is  a  matter  of  anatomic  inference,  however,  as  it  cannot  possibly  be 
separated  from  the  liver  dulness  which  meets  it.  This  anatomic  re- 
lationship may  be  facilitated  in  the  delimitation  by  ascertaining  the 
position  of  the  apex-beat,  a  straight  line  from  which,  traced  inward 
to  the  upper  border  of  the  liver  dulness,  may  be  considered  a  dividing 


PERCUSSION  247 

line,  all  dulness  above  which,  on  the  left  side,  is  due  to  the  heart. 
The  outer  boundary  of  absolute  cardiac  dulness  passes  obliquely  down- 
ward and  outward  in  an  irregularly,  slightly  curved  line,  from  the 
fourth  rib  to  the  sixth,  between  the  parasternal  and  mammillary  lines. 
The  right  border  extends  along  the  left  edge  of  the  sternum,  from  the 
fourth  to  the  sixth  rib.  It  is  not  so  easily  defined  because  of  the 
peculiar  wooden  tone  of  the  sternum  when  percussed. 

The  last  statement  not  only  corroborates  the  fact  that  the  super- 
ficial area  of  marked  and  comparatively  easily  detected  dulness  is  no 
indication  of  the  size  of  the  heart  generally,  but  that  neither  does  it 
indicate  exactly  all  of  that  portion  of  the  heart  which  is  uncovered 
by  lung;  for  a  part  of  the  right  ventricle  not  overlapped  by  the  mar- 
gins of  the  lungs  lies  to  the  right  of  the  left  border  of  the  sternum, 
and  yet  the  percussion  note  over  it  (the  lower  third  of  the  sternum), 
instead  of  being  dull,  has  this  clear,  pulmonary  resonant  quality  modi- 
fied by  the  sounding-board  vibrations  of  the  bone,  so  that  the  dulness 
which  the  ventricle  underneath  would  otherwise  give  is  "  overborne 
by  the  clearness  of  the  pulmonary  note"  conducted  back  to  the  per- 
cussion point  of  transmission. 

The  clinical  value  of  the  superficial  area  of  cardiac  dulness  is 
very  much  less  than  that  of  the  deep  or  relative  dulness,  therefore, 
in  estimating  the  size  of  the  heart,  because  the  extent  of  dulness 
varies  with  the  position  of  the  lung  borders,  which  are  themselves 
variable  even  in  the  healthy  individual,  due  to  the  inspiratory  and 
expiratory  movements,  and  the  conditions  of  age.  As  to  the  latter, 
the  absolute  dulness  begins  a  little  higher  in  children  (third  inter- 
space), while  in  old  age  the  extent  of  dulness  is  smaller,  from  senile 
inflation  of  the  lungs,  so  that  the  upper  boundary  begins  usually  at 
the  fifth  rib,  and  the  outer  at  the  parasternal  line. 

Pathologically,  although  enlargement  of  the  heart  does  cause  some 
increase  in  the  dimensions  of  the  area  of  exposed  dulness,  by  pressing 
the  lung  borders  aside  somewhat,  shrinking  of  the  left  lung  without 
such  enlargement  will  manifest  the  same  signs.  Then,  again,  emphy- 
sematous  encroachment  upon  the  heart  area  will  so  diminish,  or  even 
obliterate,  the  dulness  as  to  preclude  entirely  any  indications  of  the 
cardiac  size  by  this  method. 

The  deep  or  covered  dulness,  however,  is  of  decided  importance 
as  an  index  of  the  actual  size  of  the  heart,  the  limits  of  dulness  cor- 
responding with  a  much  nearer  exactitude  to  those  of  the  organ  itself, 
regardless  of  the  position  of  the  lung  borders.  The  relative  dulness 
is  best  demonstrated  at  the  upper  and  outer  limits  of  the  heart  area. 


248 


PHYSICAL    DIAGNOSIS 


Thus  it  occupies  a  narrow  zone  of  muffled  resonance,  the  width  of 
an  interspace,  beyond  the  left  lung  border — that  is,  beyond  the  upper 
and  outer  margins  of  the  area  of  absolute  dulness — being  found  in 
the  third  interspace  inside  the  left  parasternal  line,  and  following  a 


FIG.  45. — SHOWING  THE  EXPOSED  AND  COVERED  DULNESS  OF  THE  NORMAL  HEART. 

(Butler.) 

downward  and  outward  course  across  the  fourth  interspace  and  fifth 
rib  into  the  fifth  interspace,  at  the  apex,  where  it  terminates.  Hence, 
in  the  fourth  and  fifth  interspaces,  where  the  relatively  dull  zone  is 
nearly  vertical  in  direction,  it  lies  between  the  parasternal  and  nipple 
lines.  Within  the  apex  point  the  deep  dulness  extends  to  the  right 
in  a  straight  line  to  join  the  absolute  dulness  in  the  parasternal  line, 
and  here  immediately  passes  into  the  inseparable  liver  dulness  as  far 
as  the  right  border  of  the  heart,  a  little  beyond  the  right  sternal  line. 
The  right  boundary  of  the  covered  dulness  extends  along  the  right 
edge  of  the  sternum,  from  the  fourth  rib  to  the  sternoxiphoid  junc- 
tion; it  is  detected  with  difficulty  on  account  of  the  thickness  of  the 
lung  tissue,  and  the  fact  that  when  the  most  forcible  percussion 
strokes  are  applied  close  to  or  over  the  sternum  the  resonance  set  up 
by  the  vibration  of  the  surrounding  lung  structure  overshadows  any 


PERCUSSION  249 

dulness  elicited.  And  yet  it  should  be  borne  in  mind  that  the  right 
auricle  reaches  as  far  as  one  and  a  half  fingerbreadths  to  the  right 
of  the  right  border  of  the  sternum.  But  in  lateral  enlargements  of 
the  heart  this  deeper  dulness  may  be  perceived  here. 

It  will  be  seen,  therefore,  that  the  total  area  of  cardiac  dulness 
which  can  be  mapped  out  by  firm  percussion,  the  superficial  area 
bordered  to  the  right,  left,  and  above  by  the  deep  dulness,  represents 
as  nearly  as  possible  the  anatomic  outline  of  the  heart :  laterally,  from 
about  1  in.  to  the  right  of  the  right  sternal  margin  in  the  fourth 
interspace  to  the  nipple  line  in  the  fifth, .  and  vertically,  from  the 
lower  edge  of  the  third  rib,  at  the  left  of  the  sternum.,  to  the  upper 
edge  of  the  sixth  rib  in  the  parasternal  line,  where  it  joins  the  hepatic 
dulness. 

It  should  not  be  forgotten,  also,  that  the  heart  is  constantly, 
rhythmically  changing  its  size  with  systole  and  diastole,  so  that  the 
dermographic  lines  of  delimitation  will  vary  slightly  with  different 
examiners,  or  at  different  times  with  the  same  examiner  if  deeper 
or  shallower  breathing  and  corresponding  changes  in  the  extent  of  the 
lung  borders  are  likewise  factors. 

Another  point :  Deep  percussion  over  the  sternum,  above  the  level 
of  the  third  rib,  may  develop  a  conoidal  area  of  dulness  rising  above 
the  cardiac  area,  but  joined  to  it  as  the  latter  is  to  the  hepatic  below. 
This  is  due  to  the  aorta  and  pulmonary  artery,  but  principally  the 
former.  Aortic  dulness,  extending  considerably  beyond  the  sternal 
margins  in  the  second  interspace,  would  be  suggestive  of  aortic  dila- 
tion, either  diffuse  of  the  arch,  as  from  fatty  degeneration  and  weak- 
ening of  the  walls,  or  aneurismal. 

Continued  practise,  concentrated  attention,  and  careful  judgment 
are  always  a  sine  qua  non  in  estimating  the  separate  or,  more  impor- 
tant, the  entire  areas  of  the  heart  dulness.  In  order  to  facilitate 
accuracy,  a  satisfactory  technic  or  mode  of  procedure  should  be 
adopted  and  rigidly  followed,  once  skill  is  thus  acquired. 

Technic  of  Cardiac  Percussion. — We  aim  to  determine  the  entire 
area,  limits,  and  shape  of  the  deep  or  covered  heart  dulness  with  as 
much  accuracy  as  possible.  The  pleximeter  finger  should  be  applied 
firmly  and  evenly  in  the  interspaces,  and  the  plexor  strokes  should 
be  given  rather  forcibly.  With  an  anatomic  conception  of  the  usual 
topographic  and  relational  extent  and  limits  of  the  heart,  the  exam- 
iner endeavors  to  approach  these  in  lines  perpendicular  to  the  sup- 
posed outline,  beginning  always  over  fully  resonant  lung  tissue,  and 
noting  instantly  with  the  ear  the  slightest  elevation  of  pitch  and 


250  PHYSICAL    DIAGNOSIS 

change  in  quality  and  intensity,  as  well  as  any  increased  sense  of 
resistance.  Wherever  the  relative  dulness  is  first  noticed  a  mark  may 
be  made  with  a  greased  crayon,  a  line  connecting  the  marks  repre- 
senting the  probable  outline  of  the  heart. 

While,  in  approaching  the  area  of  cardiac  dulness,  it  is  proper,  if 
not  almost  natural,  to  place  the  pleximeter  finger  parallel  to  the  sup- 
posed border  of  the  heart,  a  word  of  caution  is  needed  in  estimating 
the  lateral  extent  of  the  area.  Here,  of  course,  the  finger  must  be 
placed  across  the  ribs,  the  percussion  of  which  interferes  with  the 
true  note  of  the  underlying  structures;  but  by  percussing  the  finger 
tips  applied  in  the  interspaces  only,  either  at  right  angles  or  parallel 
with  the  ribs,  confusing  and  misleading  bone  sounds  may  be  elim- 
inated. 

From  the  position  and  relations,  and  from  the  formation  of  the 
heart,  it  must  be  apparent  that  although  we  can  percuss  out  nearly 
its  entire  limits,  for  practical  purposes  this  is  not  necessary;  in  ni<>~i 
cases  it  will  suffice  to  ascertain  merely  the  extent  of  cardiac  dulnr-- 
along  two  lines — viz.,  a  vertical  and  a  transverse  one.  For  the  first 
one  we  use  the  parasternal  line  (left) ;  that  is,  about  1£  in.  to  the  left 
of  the  sternal  margin.  Percussing  strongly,  we  begin  in  the  second 
interspace  in  this  line.  We  find  here,  in  the  normal  condition,  the 
clear,  loud,  low-pitched  lung  resonance  to  the  upper  border  of  the 
third  rib.  In  the  third  interspace  there  is  a  slight  rise  in  pitch, 
diminution  in  intensity  and  duration,  and  dulling  of  quality  of  the 
pound.  Below  the  lower  border  of  the  fourth  rib  the  note  has  become 
quite  dull  and  higher  in  pitch;  in  the  fifth  interspace  it  is  flat,  short, 
empty,  or  toneless.  The  rise  in  pitch  by  these  successive  gradations, 
as  in  playing  the  notes  of  a  musical  scale,  I  have  been  in  the  habit 
of  demonstrating  by  applying  simultaneously  the  first,  second,  and 
third  pleximeter  fingers  (from  below  upward)  in  the  second,  third, 
and  fourth  interspaces,  and  percussing  them  in  rapid  order.  Below 
the  sixth  rib  the  absolute  dulness  becomes  again  relative,  and  then 
clear  because  of  gastric  and  intestinal  tympany. 

Similarly,  in  marking  out  the  lateral  or  transverse  boundaries  we 
percuss  from  without  inward  until  a  rise  in  pitch  signifies  that  we  are 
over  airless  (cardiac)  structure.  On  the  left  side  we  may  delimit 
the  curving,  oblique  heart  border  by  percussing  inward  in  each  inter- 
space, beginning  in  the  first  or  second,  until  dulness  is  reached  in  the 
slightest  degree;  in  the  same  way  the  third,  fourth,  and  fifth  inter- 
spaces are  percussed  from  lung  to  heart,  always  beginning  far  enough 
out  so  as  to  obtain  the  pure  resonance  or,  as  it  were,  standard  or 


PERCUSSION 


251 


keynote,  the  first  dulling  or  acoustic  deviation  from  which  we  are  to 
perceive.  "  In  this  way  the  true  apex  of  the  heart  is  found,  a  point 
of  importance  when  auscultation  is  followed,  and  which  is  to  be  dis- 
tinguished from  the  precordial  pulsation  in  other  positions,  often 
erroneously  called  the  apex-beat"  (Gibson  and  Russell).  To  define 


FIG.  46. — SHOWING  THE  PRINCIPAL  LINES  (NUMBERED  IN  ORDER  OF  PERFORMANCE) 
ALONG  WHICH  PERCUSSION  SHOULD  BE  CONDUCTED  TO  ASCERTAIN  THE  AREA  OF 
CARDIAC  DULNESS,  BOTH  COVERED  AND  EXPOSED.  Compare  with  Fig.  45. 
(Butler.) 

the  right  boundary  of  the  organ,  one  proceeds  in  a  corresponding 
manner,  from  the  right  midclavicular  or  parasternal  line  toward  the 
sternum,  first  determining  the  upper  boundary  of  deep  or  covered 
liver  dulness,  however,  which  is  usually  in  the  fifth  interspace  (rarely 
the  fourth),  and  then  percussing  successively  in  the  second,  third, 
and  fourth  interspaces  until  relative  dulness  is  elicited  with  forcible 
strokes. 

That  there  is  more  technical  difficulty  in  outlining  the  right  edge 
of  the  heart  by  percussion  is  explicable  from  the  fact  of  the  "  depth 
of  lung  between  the  parietes  and  the  part  of  the  heart  to  the  right  of 
the  sternum "  being  considerable,  and  because  "  the  difference  in 


252  PHYSICAL   DIAGNOSIS 

sound  when  we  pass  from  lung  to  lung  with  underlying  heart  is 
correspondingly  slight." 

While  the  delimitation  of  the  lower  border  of  the  heart  is  of  much 
less  importance,  and  rather  difficult  per  &e,  a  few  practical  points 
may  be  heeded  which  usually  avail.  In  the  first  place,  a  line  drawn 
joining  the  inferior  limits  of  the  markings  of  the  lateral  boundaries 
represents  this  border  fairly  accurately.  Furthermore,  this  trend  may 
be  indicated  by  a  finger's  breadth  of  tympanoresonance  just  below 
and  a  little  distance  inside  the  apex,  between  the  cardiac  and  hepatic 
dulnesses.  Even  within  the  parasternal  line,  however,  where  the  dul- 
ness  joining  liver  and  heart  is  almost,  if  not  quite,  uniform  on  super- 
ficial examination,  the  transition  may,  nevertheless,  be  detected  very 
frequently  by  perceiving  a  difference  in  the  character  of  the  dulness 
and  the  sensation  of  resistance.  According  to  Gibson  ("Diseases  of 
the  Heart  and  Aorta,"  p.  137),  the  best  method  of  ascertaining  this 
lower  boundary  of  the  heart  is  to  "  map  out  the  entire  areas  occupied 
by  the  two  organs,  when  a  line  drawn  from  the  angle  where  the  mar- 
gins— ascertained  by  the  deep  dulness  of  the  two  viscera — meet,  to 
the  right  of  the  sternum,  is  to  be  drawn  to  the  point  where  the  left 
end  of  the  liver  and  the  lower  margin  of  the  heart  are  found  to  be 
in  contact." 

Exceptions. — In  women,  on  account  of  the  size  and  sensitiveness 
of  the  mammas,  it  may  be  impossible  to  determine  the  size  of  the 
heart  by  percussion.  Recourse  then  may  be  had  to  an  approximation 
of  the  size  by  locating  the  apex-beat  by  palpation.  If  normal,  the 
latter  is  found  \  or  1  in.  within  the  midclavicular  (not  nipple)  line 
in  the  fifth  interspace. 

Again,  in  young  children,  owing  to  the  thinness  and  elasticity  of 
the  chest  walls,  percussion  must  be  practised  with  extreme  lightness 
of  stroke,  so  as  to  avoid  setting  into  vibration  the  adjacent  clear  lung 
and  stomach  sounds  to  the  confusion  of  the  cardiac  dulness.  Also,  it 
must  not  be  forgotten  that  in  children  the  area  of  superficial  or  ex- 
posed dulness  is  relatively  greater  at  the  upper  and  outer  borders, 
extending  to  the  third  intercostal  space. 

Other  methods,  such  as  Sansom's  pleximetric  percussion,  repercus- 
sion, palpatory  and  auscultatory  percussion,  have  certain  auxiliary 
and  precise  values,  but  are  ordinarily  impracticable. 


PERCUSSION 


253 


ABNORMAL   AREAS    OF    CARDIAC    DULNESS 

The  area  of  cardiac  dulness  may  be  increased,  diminished,  abol- 
ished, or  dislocated. 

(1)  Increase  of  Heart  Dulness.  (a)  HYPERTROPHY  AND  DILA- 
TION OF  THE  HEART. — Enlargement,  due  to  the  usual  combination 
of  thickened  and  overstretched  walls  of  the  heart  (hypertrophic  dila- 
tion), is  inferred  by  the  following  physical  signs  of  topographic  per- 
cussion: If  the  area  of  dulness  (deep)  is  increased  in  all  directions, 
but  especially  more  transversely  than  upward,  in  the  fourth  and  fifth 
interspaces,  the  dilation  and  hypertrophy  probably  affect  both  ventri- 
cles, the  extreme  left  .border  of  the  dulness  being  found  a  trifle  outside 
the  apex-beat.  When  hypertrophy  predominates,  a  powerful  apex- 
beat  and  cardiac  shock  are  palpable,  while  when  dilation  supervenes, 
the  shock  may  be  absent,  and  the  apex-beat  diffuse  and  weak.  The 
dulness  may  be  detected  1  in.  beyond  the  left  midclavicular  line,  also 
to  the  right  of  the  sternum  as  high  as  the  fourth  costal  cartilage. 
To  the  left  of  the  sternum,  as  far  as  the  parasternal  line,  the  dulness 
may  be  more  marked  than  normal  in  the  third  interspace.  Over  the 
sternum,  below  this  level,  the  resonance  is  likely  to  be  muffled  slightly. 


FIG.  47. — NORMAL  AREA  OF  ENTIRE  CARDIAC  DULNESS.  The  dotted  lines  above  and 
below  represent  the  borders  which  are  difficult  to  delimit,  but  the  apex-beat  and 
the  finding  of  the  solid-lined  portions  of  the  borders  enable  a  satisfactory  determi- 
nation of  the  size  and  shape  of  the  heart.  (Butler.) 

Increase  of  dulness  to   the  left  and  slightly  downward  indicates 
enlargement  of  the  left  ventricle.     If  the  area  of  dulness  over  the 


254 


PHYSICAL    DIAGNOSIS 


apex  is  pointed,  and  the  apex-beat  is  strongly  palpable,  hypertrophy 
predominates.     If,  on  the  other  hand,  the  extension  of  dulness  to  the 


FIG.  48. — DI-LNKSS  IN  HYPERTROPHY  OF  THE  LEFT  VENTRICLE.  Apex-beat  heaving 
and  carried  down  and  to  the  left,  perhaps  outside  of  the  apex  outline.  A  pox 
pointed.  (Butler.) 

left  has  a  rounded  apical  outline,  with  a  wavy,  diffuse  apical  impulse 
felt  propagated  to  the  right  (within  the  apex  region),  dilation  is 
predominant.  In  the  extreme  cases  of  hypertrophic  dilation  of  the 


Fia.  49. — DULNESS  IN  HYPERTROPHY  AND  DILATION  OF  THE  RIGHT  HEART.  Note 
apex-beat  moved  to  the  left,  and  dulness  increased  to  the  right  of  the  sternum. 
(Butler.) 

left  ventricle,  due  to  the  prolonged  effect  of  insufficiency  of  the  aortic 
valve,  the  left  border  of  deep  or  relative  dulness  may  reach  the  mid- 


PERCUSSION 


255 


axillary  line  in  the  sixth  or  seventh  interspace,  and  the  absolute  dul- 
ness  as  far  as  the  anterior  axillary  line  nearly. 

Increase  of  the  dulness  to  the  right,  especially  if  noted  in  the 
third  and  fourth  interspaces,  points  to  enlargement  of  the  right  auricle 
(which  is  quite  dilatable  in  direct  and  indirect  obstructions  to  the 
flow  of  blood),  and  of  the  right  ventricle.  But  in  cases  where  the 
latter  is  much  dilated,  there  is  simultaneous  extension  of  the  left 
border  of  dulness,  owing  to  the  more  horizontal  position  which  the 
heart  assumes,  which  displaces  the  apex  somewhat  to  the  left.  The 
sternal  resonance  is  modified. 

With  marked  hypertrophy  of  the  left  ventricle,  the  general  shape 
of  the  cardiac  dulness  preserves  a  triangular  outline,  while  with  dila- 


FIG.  50. — SHOWING  THE  DULNESS  DUE  TO  .  DILATION  AND  HYPERTROPHY  OF  BOTH 
VENTRICLES.  Apex  rounded  and  apex-beat  diffused.  Compare  with  Figs.  48 
and  49.  Shows  also  (first  and  second  right  interspaces)  the  dulness  of  aortic 
aneurism.  (Butler.) 

tion  of  the  right  or  of  both  ventricles,  a  quadrilateral  outline  is  more 
commonly  detected. 

Circumscribed  dulness  in  the  second  left  interspace,  close  to  the 
sternum,  is  quite  constant  in  mitral  stenosis. 

(b)  PERICARDIAL  EFFUSION". — Simultaneous  extension  of  the  area 
of  cardiac  dulness  toward  both  sides  and  upward  denotes  a  liquid 
effusion  into  the  pericardial  sac.  If  the  quantity  of  fluid  is  large, 
the  area  of  dulness  takes  the  form  of  the  distended  sac,  and  thus  is 
irregularly  triangular  or  pyramidal  (sometimes  almost  equilateral) 
in  outline,  the  base  being  downward,  where  the  enlargement  begins 
and  shows  the  most.  The  limits  of  dulness  to  the  right  and  left  here 


256 


PHYSICAL    DIAGNOSIS 


depend  upon  the  size  of  the  effusion;  if  very  abundant,  the  base  of 
the  triangle  may  extend  from  the  right  parasternal  line  in  the  fifth 
interspace  to  the  left  anterior  axillary  line  almost.  At  the  same  time 
the  apex  of  the  dull  area  may  reach  to  the  second  interspace,  where 
the  converging  outlines  of  dulness  meet  from  below,  to  form  a  rounded 
obtuse  angle.  The  distention  of  the  lower  portion  of  the  pericardial 
sac  is  recognized  by  the  fact  that  the  apex-beat,  or  on  auscultation 
the  point  of  greatest  intensity  of  the  first  sound,  is  found  to  be  well 
inside  the  limits  of  dulness.  A  less  considerable  quantity  of  exudation 
gives  rise  to  a  proportionately  smaller  area  of  dulness,  extending 
probably  but  a  trifle  beyond  the  nipple  line,  within  which  the  apex- 
beat  may  be  felt. 

It  is  distinctive  that  in  large  pericardial  effusions  the  area  of 
dulness  is  altered  by  changing  the  position  of  the  patient,  in  the 

sitting  posture  being  larger  than 
in  the  recumbent;  the  sternal 
resonance  may  then  be  abolished. 
Another  feature  is  the  absence  of 
any  distinction  between  the  deep 
or  covered  and  the  superficial  or 
exposed  dulness,  the  overlapping 
lung  being  pushed  aside  and  leav- 
ing the  uniform  dulness  of  the 
distended  sac.  Again,  for  the 
same  reason,  it  is  characteristic 
that,  in  approaching  the  dull 
area,  a  narrow  zone  of  tympa- 
nitic  resonance  is  percussed  just 
before  an  abrupt  transition  to 
the  effusion  flatness.  When  the 
fluid  happens  to  be  the  mobile 
transudation  of  hydropericardi- 
um,  changes  in  the  clearness  or 
dulness  of  the  borders,  or  of  the  extent  of  dulness,  on  changing  the 
patient's  position  to  the  back  or  either  side,  are  still  more  evident. 

(c)  APPARENT  INCREASE  OF  THE  CARDIAC  DULNESS  AND  SIZE 
OF  THE  HEART. — In  the  first  place,  this  may  be  due  to  retraction  of 
the  lung  over  a  normal  heart,  the  determination  of  the  complete 
outline  of  which  will  show  that  the  exposed  area  of  cardiac  dulness 
only  is  affected;  the  absence  of  mobility  of  the  border  of  the  lung 
confirms  the  fact  of  the  apparent  increase  of  heart  dulness.  Secondly, 


FIG.  51. — ABSOLUTE  DULNESS  IN  CASE 
OF  ACUTE  PERICARDITIS.     (Babcock.) 


PERCUSSION"  257 

this  may  occur  also  as  a  result  of  a  pushing  forward  of  the  heart  by 
a  tumor  or  aneurism  in  the  posterior  mediastinum.  In  the  third 
place,  apparent  increase  of  cardiac  dulness  may  be  observed  where 
the  adjacent  lung  is  consolidated  or  the  pleura  thickened.  But  by  the 
method  of  percussion  alone  it  may  be  impossible  to  determine  where 
heart  dulness  begins  and  pulmonary  or  pleural  dulness  ends;  the 
position  of  the  apex-beat,  the  character  of  the  vocal  fremitus  and 
breath  sounds  must  be  solicited  as  aids  in  the  diagnosis. 

(d)  It  remains  to  note  actual  INCREASE  OF  THE  PRECORDIAL  DUL- 
NKSS  UPWARD,  because  of  disease  of  the  aorta  especially.  Extension 
of  dulness  above  the  normal  cardiac  area,  and  to  the  right  of  the 
sternum,  usually  means  aneurism  of  the  ascending  portion  of  the  aortic 
arch ;  over  the  manubrium,  of  the  transverse  portion ;  to  the  left  of 
the  sternum,  in  the  first  and  second  interspaces,  of  the  descending 
portion  at  its  beginning.  Aneurismal  dulness  is  thus  commonly  a 
smaller,  rounded  area  of  dulness,  superposed  and  connected  with  the 
larger,  triangular  area  of  cardiac  dulness. 

(2)  Diminished  and  Absent  Cardiac  Dulness. — As  the  area  of 
absolute  or  exposed  cardiac  dulness  depends  upon  the  extent  of  the 
overlapping  lung  borders,  and  as  the  deep,  relative,  or  covered  dulness 
depends  upon  the  thickness  of  the  same  as  well,  it  is  evident  that 
any  diminution  of  these  areas  (but  especially  of  the  superficial  area) 
must  mean  some  encroachment  upon  the  boundaries  of  the  heart  by 
air-containing  tissue.     This  condition  is  most  typically  illustrated  in 
cases  of  emphysema  of  the  lungs.     In  very  marked  instances  of  the 
latter  the  cardiac  dulness  may  be  totally  absent.     In  moderate  cases 
the  heart  outline  may  be  percussed  by  the  heaviest  strokes.     As  the 
heart  in  advanced  cases  of  emphysema  is  frequently  enlarged   (right 
ventricle),  there  is  often  difficulty  in  detecting  it  by  percussion  be- 
cause of  the  interposed  enlarged  lung.     So  that  a  normal-sized  area 
of  cardiac  dulness,  with  the  existence  of  emphysema,  would  really 
indicate  a  considerable  enlargement  of  the  heart. 

The  heart  dulness  is  absent,  also,  owing  to  the  presence  of  air 
in  the  pericardium  —  pneumopericardium —  from  injury,  as  stab 
wounds;  there  is  then  a  tympanitic  resonance  heard  in  percussing 
over  the  heart.  Similarly,  the  juxtaposition  of  a  left  pneumotliorax, 
'or  of  a  gaseous  distention  of  the  stomach,  may  prove  deceptive  in 
causing  a  loud,  deep  resonance  or  tympany  in  the  pracordial  area. 

(3)  Displaced  Cardiac  Area  of  Dulness. — Whether  the  heart  dul- 
ness, in  cases  of  its  dislocation,  can  be  elicited  or  not  depends  upon 
the  cause.     If  within  the  reach  of  the  percussion  strokes  at  all,  its 

19 


258  PHYSICAL    DIAGNOSIS 

size  and  outlines  will  correspond  with  those  of  the  heart  itself  pretty 
nearly.  The  causes  of  displacement  have  been  given  under  inspection 
and  palpation,  in  connection  with  displacements  of  the  apex-heat; 
indeed,  when  palpable,  the  position  of  the  apex-beat  aids  materially 
in  locating  the  heart  dulness.  Even  then  it  may  be  impossible  to 
delimit  the  cardiac  dulness  throughout,  when,  as  often  happens,  the 
cause  of  the  displacement  as  a  pleuritic  exudation  itself  gives  dulness 
on  percussion. 

The  dislocated  area  of  dulness  of  a  dislocated  heart  may  thus  be 
normal  in  size;  it  may  be  smaller  than  normal,  as  when  the  heart  is 
drawn  under  and  away  from  the  chest  wall  by  pleural  adhesions  and 
shrinking  of  the  lung,  or  it  may  be  increased  because  of  a  larger 
parietal  contact  with  the  chest  wall  when  the  heart  is  pushed  up 
against  it  by  a  high  position  of  the  diaphragm.  Moderate  displace- 
ment of  the  heart  to  the  right,  under  the  sternum,  as  from  emphy- 
sema, is  designated  as  mesocardia.  Extreme  displacement  to  the  right, 
as  in  very  large  left-sided  pleural  effusions,  or  in  transposition  of  the 
viscera  (situs  inversus),  is  known  as  dextrocardia. 


CHAPTEE    XII 
AUSCULTATION 

Auscultation  may  be  considered  the  diagnostic  climax  in  the 
physical  examination  of  the  heart ;  not  necessarily  a  method  of  inde- 
pendent value  and  reliability,  but  one  which  affords  the  most  positive, 
precise,  and  complete  data,  without  which  those  obtained  by  inspec- 
tion, palpation,  and  percussion  would,  combined,  fall  far  short  of 
indicating  the  physical  condition  of  the  heart  and  its  valves.  Indeed, 
the  perfection  or  abnormality  of  the  cardiac  mechanism  may,  in  most 
cases,  be  estimated  fairly  well  from  the  character  of  the  cyclic  sounds 
alone.  Obviously,  to  determine  and  differentiate  as  fully  and  accu- 
rately as  possible  the  significance  of  variations  of  the  natural  and 
adventitious  cardiac  sounds,  auscultation  should  always  follow  the 
other  methods  of  exploration.  No  method  is  sufficient  without  the 
others;  the  data  obtainable  by  all  four  methods  must  be  collected, 
collated,  and  analytically  considered  before  any  diagnostic  conclu- 
sions are  properly  deducible. 

The  object  of  the  auscultator  is  to  find  out  the  character  of  the 
heart  sounds,  and  then  to  detect  and  study  any  adventitious  sounds 
(murmurs)  that  may  be  heard. 

METHOD    OF    EXAMINATION 

Immediate  auscultation  may  at  times  be  employed  by  an  experi- 
enced and  skilful  examiner,  to  ascertain  in  a  general  way,  as  in  emer- 
gency, the  condition  of  the  heart  sounds  or  the  presence  of  a  murmur. 
But  no  accurate  work  can  be  done  without  the  use  of  a  stethoscope. 
My  preference  is  exclusively  for  the  binaural,  with  a  small  chest  piece, 
so  that  it  may  be  placed  evenly  in  the  interspaces,  and  so  that  the 
precise  points  of  origin  of  the  particular  physical  signs  may  be  sharply 
localized.  Whatever  form  of  stethoscope  is  adopted  by  the  physician, 
whether  the  single,  ordinary  binaural,  Bowies',  or  other  pattern,  let 
him  use  that  which  continually  gives  the  best  and  most  satisfactory 

259 


260  PHYSICAL    DIAGNOSIS 

results  to  himself,  no  matter  how  favorable  the  recommendations  of 
other  instruments  by  other  men.  It  may  be  added,  however,  that  by 
immediate  auscultation,  especially  in  cases  of  hypertrophied  and 
dilated  heart,  one  may  occasionally  better  determine  the  time  during 
the  cardiac  cycle  when  the  normal  and  abnormal  sounds  occur  by 
noting  the  time  when  the  impulse  is  felt  by  the  tactile  sense  of  the 
ear.  Usually  the  practise  is  to  palpate  the  carotid  artery  with  the 
finger,  and  thus  compare  its  pulsation  with  the  heart  sounds  or 
murmurs. 

The  patient  should  be  at  rest  in  body  and  serene  in  mind,  prefer- 
ably in  a  comfortable  sitting  posture,  so  as  to  bring  the  heart  in 
close  contact  with  the  chest  wall.  Sometimes  it  may  be  necessary  to 
have  him  make  a  little  exertion  when  the  sounds  are  very  weak.  The 
resulting  increased  activity  of  the  heart  and  intensity  of  the  sounds 
may  be  obtained  by  having  the  patient  sit  up  in  bed,  or  turn  over 
several  times,  or,  if  out  of  bed,  bend  the  body  backward  and  forward 
a  few  times  while  standing,  or  step  off  a  few  paces  briskly. 

THE    NORMAL    HEART 
NORMAL  HEART  SOUNDS 

When  the  stethoscope  is  applied  over  the  body  of  the  heart,  in 
the  third  and  fourth  interspaces,  within  and  in  the  left  parasternal 
line,  we  hear  sounds  and  silences  or  pauses  rhythmically  alternating. 
Indeed,  they  may  be  distinctly  audible  all  over  the  precordium,  and 
for  some  distance  beyond  it  on  both  sides  of  the  chest;  faintly,  even 
posteriorly,  in  certain  individuals  with  thin  thoracic  walls.  The  pre- 
dominant sound  is  found  to  be  synchronous  with  the  apex-beat  and 
carotid  pulse  as  palpated  with  the  finger,  and  hence  is  called  the 
systolic  or  first  sound,  because  it  coincides  with  these  phenomena  of 
the  systole  or  ventricular  contraction  of  the  heart.  An  extremely 
short  pause  follows,  which  is  in  turn  followed  by  a  different  sound, 
the  second,  or  diastolic.  This  sound  occurs  at  the  beginning  of  a 
longer  pause,  corresponding  to  the  diastole.  These  two  sounds  are 
often  traditionally  represented  by  the  respective  monosyllables,  lub- 
dub.  Thus  the  first  sound  and  short  pause,  second  sound  and  long 
pause  constitute  a  complete  cardiac  cycle.  This  rhythm  of  sounds 
and  silences  is  not  apparent  in  infants,  where  the  former  are  alike  in 
character  and  the  latter  in  duration,  similar  to  the  uniform  ticking 
of  a  watch.  In  the  adult,  therefore,  how  do  we  distinguish  between 
these  two  sounds  in  themselves?  The  answer  is:  By  their  attributes. 


AUSCULTATION 


261 


Short  pause  - 
Second  sound- 


Long  pause. 


First  sound. 

Short  pause. 
Second  sound  - 


Long  pause 


First  sound' 


j  V  Auricular 
y  systole 

1 

Ventricular 
systole 


-Diastole 


First  Sound. — The  quality  of  the  systolic  sound  is  a  dull  booming 
"lub."  The  inlatxiti/  is  comparatively  marked.  The  pitch  is  rela- 
tively low.  The  duration  is 
long. 

Second  Sound. — The  quality 
of  this  sound  is  sharp,  snap- 
ping, or  clicking.  Its  intensity  First  sound 
is  less  loud  than  that  of  the 
first  sound.  The  pitch  is  dis- 
tinctly higher  than  the  other. 
The  duration  is  shorter.  In 
other  words,  the  first  sound 
is  heavier,  louder,  lower,  and 
longer  than  the  second;  or, 
conversely,  the  second  sound 
is  snappier,  softer,  higher,  and 
shorter. 

Although  the  first  and  sec- 
ond heart  sounds  may  be  heard 
over  the  whole  precordiunr, their 
accent  varies  at  different  points, 
while  the  rhythm  remains  the 
same.  Thus,  since  the  first 
sound  corresponds  with  the 
ventricular  systole,  its  accent- 
uation is  heard  at  that  point  Short  pause/ 

Second  sound  s 


i) 
|U  >.  Auricular 

systole 


Ventricular 
systole 


>  Diastole 


•  Auricular 

systole 


I  >  Ventricular 
systole 


FIG.  52. — NORMAL  CARDIAC  CYCLE.  Phases 
of  cycle  to  the  right  of  line;  sounds  to  the 
left.  (Babcock.) 


\vhere  the  ventricular  conduc- 
tion of  sound  is  best  heard, 
namely,  at  or  near  the  apex. 
On  the  other  hand,  the  second 

sound  is  accentuated  at  the  base  of  the  heart,  corresponding  as  it 
does  with  the  general  location  of  the  aortic  and  pulmonary  valves, 
whose  simultaneous  closure  at  the  commencement  of  diastole  is  the 
physiologic  explanation  of  this  sound. 

Causes  of  the  Heart  Sounds. — The  first  sound  is  produced  by  the 
synchronus  closure  of  the  mitral  and  tricuspid  valves,  and  the 
synchronous  contractions  of  the  right  and  left  ventricles.  Proba- 
bly the  sudden  rush  of  blood  due  to  the  filling  of  the  beginnings 
of  the  pulmonary  artery  and  aorta  (the  coni  arteriosi),  and  the 
impact  of  the  apex  against  the  chest  wall,  are  contributory  factors 
also. 


262  PHYSICAL   DIAGNOSIS 

The  second  sound  is  undoubtedly  the  result  of  the  sharp  closure, 
synchronously,  of  the  pulmonary  and  aortic  valves.  Thus  it  will  be 
noticed  that  both  sounds  are  caused  practically  by  valvular  action, 
although,  as  will  be  indicated  later,  the  character  of  the  first  sound 
may  be  altered  considerably  in  affections  influencing  the  vigor  of 
the  muscular  contractions  primarily,  and  thus,  in  a  measure,  the  force 
of  closure  of  the  auriculoventricular  valves  secondarily. 

The  Cardiac  Cycle. — The  mode  of  production  of  the  two  heart 
sounds  will  be  understood  better,  perhaps,  by  rehearsing  the  physio- 
logic movement  of  the  blood  through  the  heart,  and  then  simply 
summarizing  the  actual  cardiac  movements  themselves  as  they  blend 
in  normal  rhythm.  Concerning  the  former,  I  may  quote  with  ad- 
vantage the  clear  and  graphic  statements  of  Vierordt :  "  The  blood 
flows  from  the  body  through  the  caves  into  the  right  auricle,  from 
whence,  during  the  ventricular  diastole,  it  passes  through  the  right 
auriculoventricular  opening,  the  tricuspid  valve,  into  the  right  ven- 
tricle, being  urged  forward  toward  the  end  of  the  diastole  by  the 
weak  muscular  contraction  of  the  right  auricle.  The  systole  which 
immediately  follows  drives  the  blood  out  of  the  ventricle,  the  tricuspid 
valve  being  at  the  same  time  closed,  through  the  open  pulmonary 
sernilunar  valve  into  the  pulmonary  artery.  The  blood,  prevented 
from  flowing  back  into  the  ventricle  during  the  diastole,  which  imme- 
diately follows,  by  the  closure  of  the  pulmonary  semilunar  valve, 
passes  through  the  lungs,  and  from  them  flows  into  the  left  auricle, 
whence,  by  the  diastole  of  the  ventricle,  it  flows  through  the  left 
auriculoventricular  opening,  the  mitral  valve,  into  the  left  ventricle, 
whither  it  is  again  assisted  at  the  end  of  the  diastole  by  the  contrac- 
tion of  the  auricle.  The  left  ventricle  discharges  its  contents  during 
the  systole  (the  mitral  valve  being  closed)  into  the  commencement 
of  the  aorta,  through  the  open  aortic  semilunar  valve,  whence  it  is 
prevented  from  returning  to  the  ventricle  when  the  pressure  from 
the  ventricle  ceases  and  the  diastole  begins,  by  the  closure  of  the 
aortic  semilunar  valve.  The  blood  then  flows  from  the  conus  aortrr 
into  the  body/' 

In  the  second  place,  however,  it  should  be  remembered  that  the 
blood  enters  the  aorta  and  pulmonary  artery  at  the  same  time  by 
the  synchronous  contractions  of  the  two  ventricles.  With  the  com- 
pletion of  this  systolic  unison,  relaxation  of  the  ventricles  ensues, 
and  at  once  the  recoil  of  the  arterial  walls  forces  the  columns  of 
blood  back  against  the  semilunar  valves,  which  close  with  the 
snap  of  sudden  tension  thus  at  the  commencement  of  the  ven- 


AUSCULTATION 


263 


tricular  diastole.  Hence,  four  sounds  are  created,  one  at  each 
valve  orifice,  normally  audible  as  two  because  of  the  simultaneous 
closure  of  each  homologous 
pair. 

In  connection  with  the 
first  or  ventricular  systolic 
sound,  Babcock  writes  as  fol- 
lows: "Physiology  teaches 
us  that  the  duration  of  this 
phase  of  the  cardiac  cycle  is 
T3oV  °f  a  second,  subdivided 
as  follows:  During  the  first 
tenth  of  a  second  the  ventri- 
cle is  initiating  its  contrac- 
tion and  is  silent;  during 
the  following  T^  of  a  sec- 
ond its  contraction  reaches 
its  maximum  energy,  the  au- 
riculoventricular  valves  close, 
and  the  first  heart  sound  is 
heard;  the  final  tenth  of  the 
second,  during  which  the 
ventricle  still  remains  con- 
tracted, is  again  a  period  of 
silence,  and  terminates  the 
phase  of  ventricular  sys- 
tole." 

To  summarize:  The  rhythm  or  time  is  the  basis  of  distinction 
between  the  first  and  second  cardiac  sounds,  apart  from  their  normal 
characteristic  attributes,  the  first  or  systolic  sound  being  that  which 
is  heard  at  the  time  of  the  normal  cardiac  impulse  or  carotid  pulse, 
or  just  before  the  radial  pulse,  the  second  sound  being  the  one  which 
follows  the  impulse.  Also,  the  sound  which  follows  the  long  silence 
is  the  first  sound;  that  which  precedes  the  long  and  follows  the  short 
silence  is  the  diastolic  or  second  sound.  The  systolic  sound  is  partly 
(mainly)  valvular  and  partly  muscular ;  the  other  purely  valvular. 

From  the  preceding  it  is  apparent  that  the  valves  are  very  essen- 
tial in  the  production  of  the  heart  sounds,  and  therefore  that  any 
alterations  of  these  sounds  must  mean  some  imperfection  in  the  func- 
tion or  structure  of  one  or  more  of  these  valves  or  their  orifices.  But 
the  heart  is  double,  and  the  problem  in  physical  diagnosis  is  to  deter- 


FIG.  53.  —  DIAGRAMMATIC  REPRESENTATION 
OF  THE  MOVEMENTS  AND  SOUNDS  OF  THE 
HEART.  (After  Sharpey.)  This  diagram 
shows  merely  the  general  relations  of  the 
several  events,  and  does  not  represent  ex- 
act measurements.  In  a  heart  beating  72 
per  minute,  Foster  estimates  each  entire 
cardiac  cycle  as  occupying  about  0.8  sec- 
ond, of  which  0.3  second  represents  the 
duration  of  the  systole  of  the  ventricles, 
0.4  second  the  diastole  of  both  auricles  and 
ventricles,  or  the  "passive  interval,"  and 
0.1  second  the  systole  of  the  auricles.  (Le 
Fevre.) 


264  PHYSICAL    DIAGNOSIS 

mine  whether  the  right  or  the  left  auriculoventricular  valve  is  at 
fault  in  causing  any  abnormality  of  the  first  or  systolic  sound,  which 
is  synchronously  produced  hy  both,  and  whether  the  right  or  left 
semi  lunar  valve  is  diseased  when  the  separately,  yet  synchronously, 
produced  second  sounds  are  altered.  Furthermore,  as  the  adventitious 
heart  sounds  known  as  murmurs  occur  in  connection  with  affections 
of  the  valves,  it  is  of  first  importance  to  know  which  of  the  four 
valves  is  the  seat  of  the  lesion. 


VALVE  AREAS 

Naturally,  one  would  auscult  at  that  point  which  is  nearest  to 
any  particular  valve  and  orifice,  but  experience  has  shown  that  the 
clinical  areas  of  differentiation  do  not  correspond  with  the  anatomic 
positions  of  the  valves.  Thus,  a  superficial  area  of  half  an  inch 
square  will  include  a  portion  of  all  four  sets  of  valves,  so  that  stetho- 
scopic  examination  here  fails  to  detect  the  valve  affected.  We  cannot 
tell  a  right  first  or  second  sound  from  a  left  first  or  second  sound,  or 
at  which  orifice  a  murmur  is  developed. 

The  respective  valve  areas  selected  for  auscultating  the  heart 
represent  the  points  to  which  the  vibrations  from  the  corresponding 
valves  are  best  conducted,  and  exhibit,  therefore,  the  greatest  intensity. 
We  have,  then,  the  mitral  area,  the  tricuspid  area,  the  aortic  area,  and 
the  pulmonary  area.  The  mitral  and  aortic  valve  sounds  are  most 
audible  at  a  greater  distance  from  their  anatomic  positions  of  origin 
than  are  the  tricuspid  and  pulmonary  because  of  their  deep  location, 
the  first  being  behind  the  overlapping  lung,  the  second  behind  the 
pulmonary  artery.  On  the  other  hand,  the  tricuspid  and  pulmonary 
valves  are  comparatively  near  the  surface  of  the  chest  wall,  and  con- 
sequently are  productive  of  sounds  which  are  distinctly  audible  near 
their  anatomic  origins. 

Areas  of  Maximum  Intensity. — The  locations  of  greatest  intensity 
of  the  first,  systolic,  or  ventricular  sound — near  the  apex — and  the 
second,  diastolic,  or  arterial  sound — at  the  base  of  the  heart — have 
already  been  indicated. 

(1)  THE  MITRAL  AREA. — The  sound  produced  by  the  closure  of 
the  mitral  valve  (at  systole)  is  best  heard  at  the  apex,  within  an 
area  about  1  in.  in  diameter.  It  is  more  audible  here  than  over  the 
precise  situation  of  the  valve,  because,  in  its  deep  origin,  it  is  con- 
ducted by  the  walls  of  the  left  ventricle  to  that  point  where  the  latter 
lies  most  closely  to  the  thoracic  wall,  namely,  the  impinging  tip. 


AUSCULTATION 


265 


(2)  THE  AORTIC  AUK  A. — The  second  right  intercostal  space  near 
the  border  of  the  sternum  is  the  point  of  maximum  loudness  of  the 
sound  of  closure  of  the  aortic  valve  leaflets.  This  is  because  the 


FIG.  54. — AREAS  OF  THE  CARDIAC  MURMURS.  (After  Gairdner  and  Luschka.)  The 
outlines  of  organs,  which  are  partially  invisible  in  the  dissection,  are  indicated 
by  very  fine  dotted  lines;  while  the  areas  of  propagation  of  valvular  murmurs,  as 
described  in  the  text,  have  been  roughly  marked  by  additional  much  coarser  and 
more  visible  dotted  lines — the  character  of  the  dots  being  different  in  each  of  the 
four  areas.  A  capital  letter  marks  each  area,  viz.:  A,  the  circle  of  mitral  murmurs 
corresponding  with  the  left  apex;  B,  the  irregular  space  indicating  the  ordinary 
limits  of  diffusion  of  aortic  murmurs,  corresponding  mainly  with  the  whole  ster- 
num, and  extending  into  the  neck  along  the  course  of  the  arteries;  C,  the  broad 
and  somewhat  diffused  area  occupied  by  tricuspid  murmurs,  and  corresponding 
generally  with  the  right  ventricle;  D,  the  circumscribed  circular  area  over  which 
pulmonic  murmurs  are  commonly  heard  loudest.  Reference  letters:  r.  au.,  right 
auricle;  a.  o.,  arch  of  aorta;  v.  i.,  the  two  innominate  veins;  v.  c.,  vena  cava  de- 
scendehs;  p.,  pulmonary  artery;  1.  au.,  left  auricle;  I.  v.,  left  ventricle;  r.  v., 
right  ventricle.  (Finlayson.) 

sound  is  propagated  along  the  course  of  the  blood  current  to  that 
portion  of  the  ascending,  tense-walled  aorta  which  is  nearest  to  the 
surface  of  the  chest  at  the  second  right  cartilage. 


266 


PHYSICAL    DIAGNOSIS 


(3)  THE  TiticusriD  A  UK  A. — The  point  of  election  in  auscultating 
the  tricuspid  element  of  the  first  sound  is  at  the  lower  part  of  the 
sternum,  especially  near  the  left  border  opposite  the  fourth  and  fifth 
interspaces.     It  is  in  this  region  that  the  right  ventricle,  uncovered 
by  lung,  is  in  close  contact  with  the  chest  wall. 

(4)  THE  PULMONIC  AREA. — The  closure  of  the  pulmonary  valve 
is  heard  best  at  the  second  left  interspace  near  the  sternal  border,  or 
at  the  sternal  end  of  the  third  left  costal  cartilage,  directly  over  Ihe 
valve  itself.    This  is  the  only  one  of  the  four  areas  for  auscultation, 
therefore,  which  coincides  practically  with  the  anatomic  position  of 
the  valve. 

The  points  of  election  just  given  are  used  in  localizing  the  seat 
of  production  of  organic  valvular  murmurs  even  more  than  for  the 


FIG.  55. — SHOWING  THE  POSITIONS  OF  THE  VALVES  OF  THE  HEART  AND  THE  AREAS 
OF  THEIR  GREATEST  AUDIBILITY.  Solid  circles  and  blocks  =  deep  valves  (aortic 
and  mitral).  Light  circles  and  blocks  =  superficial  valves  (pulmonary  and  tri- 
cuspid). (Butler.) 

purpose  of  differentiating  the  separate  valve  sounds  themselves,  al- 
though the  characters  and  changes  of  the  latter  should  be  studied  more 
frequently  and  carefully  than  is  commonly  done. 

Vierordt  summarizes  the  physiologic  events  producing  the  first 


AUSCULTATION"  267 

and  second  sounds  as  heard  at  the  four  valve  areas  in  the  following 
manner : 

"  Apex  of  the  heart  (mitral  orifice)  : 

"First  sound:  Closure  of  the  mitral  valves  and  ventricular  con- 
traction. 

"  Second  sound :  Prolonged  aortic  second  sound  (closure  of  aortic 
valve). 

"Under  the  sternum  (tricuspid  orifice}  : 

"  First  sound :  Closure  of  the  tricuspid  valves  and  ventricular 
contraction. 

"  Second  sound :   Prolonged  pulmonary  second  sound. 

"  Second  intercostal  space,  right  or  left  (aorta,  pulmonary  ar- 
tery) : 

"  First  sound :  Sudden  filling  of  the  beginning  of  the  aorta,  of  the 
pulmonary  artery,  and  continuation  of  the  first  ventricular  sound. 

"  Second  sound :  Closure  of  the  semilunar  valves  of  the  aorta,  or 
of  the  pulmonary  artery." 

PHYSIOLOGIC  VARIATIONS  OF  THE  HEART  SOUNDS 

Within  normal  limits,  the  heart  sounds  may  vary  in  strength  or 
loudness.  This  is  true  usually  of  both  sounds  together;  that  is,  they 
are  both  relatively  increased  or  diminished  in  intensity.  The  condi- 
tion may  be  temporary,  as  the  increase  of  intensity  due  to  a  full, 
stimulating  diet,  physical  exertion,  or  mental  excitement,  or  more  or 
less  persistent,  as  the  increase  from  thinness  of  the  fleshy  coverings 
of  the  chest,  as  well  as  the  flexibility  and  delicacy  of  the  bony  thorax 
in  children  and  certain  delicate  adults.  On  the  other  hand,  in  those 
with  thick,  obese  chest  walls,  and  especially  women  with  large,  fat 
mammary  glands,  both  sounds — the  first,  usually,  more  than  the  sec- 
ond, however — are  relatively,  yet  normally,  weakened.  The  heart 
sounds  are  also  less  distinctly  heard  in  an  individual  lying  down  on 
the  back  or  reclining  than  when  in  the  upright  position,  owing  to  the 
organ's  swinging  back  from  the  precordial  region. 

Thus  it  is  apparent  that  the  loudness  of  the  cardiac  sounds  de- 
pends upon  the  nature  and  thickness  of  the  media  through  which 
they  have  to  pass,  the  degree  of  blood  pressure  within  the  heart  and 
arteries,  and  the  distance  of  the  vibrating  valve  orifices  and  ven- 
tricular muscle  from  the  front  surface  of  the  chest. 

The  individual  valve  sounds  vary  also,  intrinsically,  and  according 
to  the  factors  of  age,  temperament,  vigor  of  health,  and  character  of 


268  PHYSICAL    DIAGNOSIS 

nervous  system,  occupation,  etc.  Not  only  intensity,  Imt  normal  qual- 
ity, pitch,  duration,  and  rhythmic  variations  arc  frequently  observed. 

In  childhood,  the  valvular  element  of  the  ///>•/  wand  predominates 
over  the  muscular,  and  has  a  more  ringing,  higher-pitched,  shorter 
character  than  in  the  adult.  In  the  latter,  the  first  sound  has  a  duller, 
more  booming  quality,  of  lower  pitch  and  longer  duration,  although 
in  certain  thin,  nervous  people  it  may  partake  of  the  type  of  early 
life.  In  the  very  vigorous  and  robust  the  first  sound  is  often  of  a 
loud,  prolonged,  rumbling  nature,  while  in  the  fat  and  indolent  it  is 
distant,  indistinct,  and  short.  The  sound  as  heard  in  the  tricuspid 
area  is  of  about  equal  character  and  intensity  as  that  of  the  mitral 
area,  although  at  every  age  the  latter,  or  sound  produced  by  the  left 
ventricle,  is  more  likely  to  be  a  little  heavier  than  the  other,  if  there 
is  any  difference  at  all. 

The  second  sound  is,  of  course,  louder  at  the  base  than  at  the 
apex.  Its  component  elements,  however,  differ  in  relative  intensity. 
In  childhood  the  pulmonic  sound  is  the  stronger  of  the  two,  in 
middle  life  they  are  about  equal  in  loudness,  while  in  advanced  age 
the  aortic  sound  predominates  over  the  pulmonic,  probably  because 
of  the  senile  degenerative  changes.  As  to  pitch,  in  a  series  of  nearly 
500  healthy  individuals  I  have  found  that  in  about  eighty  per  cent  the 
aortic  sound  was  slightly,  but  distinctly,  higher  than  the  pulmonic, 
the  ages  ranging  from  twenty-two  to  fifty  years  principally.  Hence, 
the  term  accentuation,  which  is  generally  applied  to  variations  of  the 
intensity  of  the  sounds,  should  not  be  used  without  careful  discrim- 
ination, and  the  proper  designation  of  the  attribute  which  may  be 
qualified.  For  if  the  aortic  sound  is  referred  to  as  accentuated,  for 
example,  the  diagnostic  interpretation  and  value  of  the  physical  sign 
will  depend  more  or  less  considerably  upon  whether  intensity  or  pitch 
is  meant.  In  regard  to  pitch,  the  designations  elevation  or  depression 
may  be  used  here,  just  as  they  appropriately  describe  variations  of  this 
attribute  in  other  connections. 

The  rhythm  of  the  first  sound  may  be  physiologically  disturbed 
in  a  so-called  doubling,  whereby  the  sound  is  divided,  but  yet  without 
any  interval  such  as  exists  between  the  first  and  second  sounds.  It 
may  be  likened  to  the  pronouncing  of  the  syllables  "  turrupp "  or 
"  trupp."  This  phenomenon  may  occur  in  health  at  the  end  of  a 
deep  inspiration  and  holding  the  breath,  although  this  is  much  more 
common  as  a  cause  of  doubling  of  the  normal  second  sound.  In  fact, 
doubled  first  sound  is  rarely  physiologic,  and  is  more  apparent  than 
real,  the  splitting  of  the  sound  being  probably  due  to  a  transient 


AUSCULTATION  269 

peculiarity  whereby  the  "  maximum  intensity  of  the  left  first  sound 
does  not  coincide  with  the  maximum  intensity  of  the  right  first 
sound."  Or  possibly  the  doubling  may  be  due  to  temporary  excite- 
ment of  the  heart,  in  which  one  hears  the  sudden  shock  communi- 
cated to  the  ventricular  contents  just  before  the  occurrence  of  the 
systole. 

Reduplication  or  division  of  the  second  sound,  while  also  occurring 
normally  sometimes,  is  usually  pathologic.  It  is  likewise  heard  in 
some  individuals  at  the  end  of  a  deep  inspiration,  the  intracardio- 
vascular  pressures  being  altered  for  the  moment,  so  that  the  pulmonary 
and  aortic  valves  fail  to  close  simultaneously. 

PATHOLOGIC    MODIFICATIONS    OF   THE    HEART 

SOUNDS 

Changes  in  the  character  of  the  heart  sounds,  individually  or  col- 
lectively, may  be  observed  in  diseased  conditions  in  connection  with 
one  or  more  of  the  attributes,  although  the  most  important  alterations 
pertain  to  the  intensity,  pitch,  and  rhythm  of  certain  sounds  as 
regards  diagnostic  and,  sequentially,  prognostic  and  therapeutic  sig- 
nificance and  trend. 

Quality. — The  first  sound  may  become  sharper  and  more  snapping, 
like  the  second  sound,  and  at  the  same  time  shorter  and  higher 
pitched,  although  the  actual  volume  (loudness)  of  sound  is  dimin- 
ished. This  flapping  quality  of  the  first  sound  indicates  weakness 
or  thinness,  or  both,  of  the  ventricular  walls,  as  met  with  in  cases  of 
marked,  chronic  debility  from  anemia,  chronic  tuberculosis,  and  the 
like,  and  in  those  phlegmatic  and  neurotic  temperaments  which  are 
often  hereditary  and  sometimes  acquired  in  certain  walks  of  life. 
This  modification  of  the  first  sound  is  not  infrequently  noticed  in 
cases  of  obstruction  of  the  mitral  orifice,  with  consequent  atrophy 
and  weakness  of  the  left  ventricle. 

The  second  sound  may  have  a  kind  of  clanging,  flopping,  or 
booming  quality,  also  lower  in  pitch.  I  have  found  this  to  be  most 
distinct  in  the  second  right  interspace,  in  very  old  persons  giving 
evidence  of  loss  of  aortic  elasticity  from  fatty  degeneration  of  the 
walls  of  the  arch,  with  dilation  of  the  aorta;  also  in  cases  of  weak 
ventricle,  the  systemic  arteries  being  normal. 

Metallic  quality  of  both  heart  sounds  indicates  usually  a  large, 
smooth-walled  pulmonary  cavity  near  the  heart,  a  pneumopericardium 
or  a  pncumothorax,  or  an  inflated  stomach. 


270  PHYSICAL    DIAGNOSIS 

Intensity. — Changes  in  intensity  or  loud  ness  may  affect  both 
sounds  equally,  or  they  may  affect  but  one  sound,  either  by  way  of 
increase — accentuation — or  diminution. 

(1)  INCREASED  INTENSITY  OF  BOTH   HEART   SOUNDS. — Essen- 
tially this  will  occur  in  all  conditions  in  which  the  blood  pressure 
of  the  pulmonary  or  systemic  circulations  is  increased.     Overaction 
of  the  heart,  therefore,  from  whatever  cause,  transient  or  permanent, 
usually   accounts   for  abnormally  increased   intensity   of   the  heart 
sounds,  provided  that  certain  adjacent  changes  may  be  eliminated. 
These  may  be  pleural  or  pulmonary  conditions,  causing  the  heart 
to  be  uncovered  more  than  normal;  consolidation  of  the  overlapping 
lung,  which  facilitates  and  exaggerates  the  conduction  of  the  heart 
sounds;  juxtaposed  cavities  in  the  lung  and  pneumothorax ;  and,  at 
times,  adherent  pericardium, 

Intensification  of  heart  sounds  from  overaction  is  witnessed  in 
cases  of  cardiac  hypertrophy,  nervous  excitement  and  palpitation, 
exophthalmic  goiter  or  Basedow's  disease,  and  in  certain  febrile  and 
anemic  states. 

(2)  DIMINISHED  INTENSITY  or  HEART  SOUNDS. — Weakening  of 
the  heart  sounds  may  be  due  to  causes  in  the  heart  itself,  or  to  the 
muffling  effect  of  interposed  structures.     Of  the  former  should  be 
mentioned   the  weakened  heart  muscle  from  the  various  causes  of 
degeneration,  often  accompanied  with  dilation,  such  as  the  toxemias 
of  prolonged  fevers,  septic  conditions,  carbonic-acid  and  other  poison- 
ing, myocarditis,  fatty  degeneration,  cardiac  weakness  from  general 
exhaustion,  as  in  shock,  hemorrhage,  and  malignant  disease,  and  the 
loss  of  compensation  in  a  hypertrophied  heart  with  valvular  lesions. 
Closely  related  to  these  affections  is  the  central  or  peripheral  paralysis 
of  the  pneumogastric. 

Under  the  second  category  may  be  put  the  conditions  which  dis- 
place the  heart  or  separate  the  heart  from  the  chest  wall  pathologically. 
Emphysema  of  the  lung,  the  enlarged  margin  of  which  masks  the 
cardiac  sounds  by  its  greater  overlapping,  pericardial  and  pleuritic 
effusions,  belong  here.  Finally,  the  heart  sounds  may  be  weakened 
relatively  by  the  interfering  effect  of  loud  rales  in  adjacent  parts  of 
the  lungs. 

(3)  MODIFIED  INDIVIDUAL  SOUNDS.     Increased  Intensity  or  Ac- 
centuation of  the  First   (Systolic)   Sound. — As  in  the  case  of  the 
two  heart  sounds  considered  together,  conditions  which  raise  or  depress 
the  power  of  the  ventricles,  or  the  pressure  of  the  systemic  or  pul- 
monary vascular  function,  will  correspondingly  and  respectively  in- 


AUSCULTATION  271 

tensify  or  lessen  the  first  sound.  Accentuation  of  this  sound  is  com- 
monly of  two  varieties :  either  the  increased  loudness  is  associated 
with  a  dull  booming,  grave,  long  character,  or  it  is  of  a  flapping, 
short  and  sharp  character.  The  first  variety  is  found  typically  in 
cases  of  marked  hypertrophy  of  the  ventricle  (left,  especially)  or 
ventricles,  and  this  is  usually  followed  by  an  abnormally  loud  second 
sound.  The  peculiar  quality  of  accentuation  of  this  sound  of  ven- 
tricular hypertrophy  may  be  due  to  a  degree  of  exaggeration  of  the 
muscular  over  the  valvular  elements. 

The  second  variety  of  accentuated  systolic  sound  is  often  due  to 
moderate  dilation  and  weakness  of  previously  hypertrophied  heart 
walls.  The  valvular  component  predominates  here,  and  the  high- 
pitched  sound  has  the  snappy  character  of  the  "  irritability  of  weak- 
ness." This  modification  of  intensity  is  noted  also  in  some  athletes 
who,  after  a  season  of  severe  efforts  in  competitive  sports,  cease  or 
relax  careful  habits  of  training  and  physical  culture;  also  in  many 
of  those  persons  who  are  conveniently  classed  as  "  neurotic,"  and  at 
the  onset  of  acute  febrile  diseases. 

A  phenomenally  intense,  slapping  character  of  the  first  sound  is 
considered  almost  diagnostic  of  mitral  stenosis  by  some  experienced 
clinicians.  Whether  or  not  the  accentuation  of  the  first  sound  is  due 
to  increased  action  or  intraventricular  pressure  on  the  right  or  left 
side  will  depend  mainly  upon  stethoscopic  localization  over  the  tri- 
cuspid  and  mitral  valve  points,  although  it  is  generally  difficult  to 
determine  the  relative  loudness  of  the  mitral  and  tricuspid  first 
sounds.  Accentuation  of  either  may  be  heard  and  inferred  because 
of  greater  distinctness  at  the  base  as  well  as  the  apex,  so  much  so 
that  the  first  sound  at  the  former  region  may  seem  louder  than  the 
second  sound,  provided,  of  course,  that  the  second  sound  is  not  abnor- 
mally weak. 

Increased  intensity  of  the  mitral  first  sound,  while  usually  due  to 
hypertrophy  of  the  left  ventricle,  as  from  chronic  interstitial  nephritis 
and  arteriosclerosis,  aortic  stenosis  and  aortic  aneurism,  the  converse 
is  not  necessarily  true;  that  is,  in  some  of  these  cases  the  sound  may, 
on  the  contrary,  be  quite  muffled. 

Individual  accentuation  of  the  tricmpid  first  sound  is  less  com- 
mon than  of  its  fellow.  When  detected,  however,  it  indicates  some 
obstruction  to  the  flow  of  blood  into  the  left  chambers  of  the  heart, 
directly  because  of  valvular  difficulty,  or  indirectly  because  of  some 
obstructive  condition  in  the  lungs,  as  emphysema.  It  often  happens, 
nevertheless,  that  accentuated  tricuspid  closure  lasts  but  a  short  time, 


272  PHYSICAL   DIAGNOSIS 

rcgurgitation  ensuing  to  relieve  the  intraventricular  pressure,  an 
accentuated  puhnonic  second  sound  continuing,  however,  as  in  most 
instances  of  mitral  and  aortic  lesions,  where  there  is  considerable 
damming  back  of  blood  into  the  pulmonary  circulation. 

(4)  DIMINISHED  INTENSITY  OF  THE  FIRST  SOUND. — This  occurs 
in  all  cases  of  weakness  of  the  ventricular  walls  from  myocarditis, 
dilation,  or  atrophy,  as  in  the  production  of  weakness  of  both  sounds. 
But  as  any  weakness  of  the  ventricular  muscle  will  influence  the 
muscular  component  of  the  first  sound  accordingly  and  primarily,  it 
is  most  important  to  estimate  the  character  of  the  first  sound  at  the 
apex,  as  likely  to  manifest  the  first  evidence  of  diminishing  strength 
of  the  left  ventricle.  This  may  be  watched  to  develop  in  the  course 
of  a  typhoid- fever  case,  as  an  example  of  absolute  muscular  feeble- 
ness due  to  the  granular  degeneration  which  takes  place  in  the  heart 
muscle.  Or,  as  the  result  of  a  relative  condition,  when  hypertrophy 
fails  to  sustain  a  previous  compensation,  and  dilation  ensues,  the  early 
sign  again  is  a  weak,  short,  flapping  character  of  the  first  sound 
(mitral),  with  a  distinct,  sharp,  valvular  quality.  Other  general  and 
local  causes  of  weakening  of  the  first  sound  are  chronic  wasting  dis- 
eases, anemias,  etc.,  and  fatty  heart,  whether  due  to  fatty  degenera- 
tion of  the  ventricular  muscle  or  to  deposit  and  infiltration  of  fat 
upon  and  between  the  muscle  fibers;  chronic  myocarditis,  especially 
mitral  insufficiency  among  valvular  disorders,  and  pericarditic  de- 
posit upon  the  heart. 

Apparent  cardiac  causes  for  weakened  systolic  sound  at  the  apex 
may  be  due  to  emphysematous  lung,  pericardial  or  pleural  effusion. 

A  word  of  caution  is  necessary  here.  Sometimes  the  first  sound 
is  almost  inaudible,  and  the  second  sound  alone  being  heard  with 
distinctness  at  the  apex  may  seem  to  be  accentuated  when  it  is  really 
not  so.  In  extreme  cases  the  first  sound  is  completely  inaudible,  so 
that  nothing  but  the  clickings  of  the  second  sound,  with  alternating 
silences  of  more  or  less  decided  duration,  are  heard. 

Vierordt  refers  to  the  diagnostic  value  of  marked  weakening  of 
the  apical  first  sound  in  cases  of  aortic  insufficiency.  He  explains 
this  as  due  to  "  the  reflux  from  the  aorta,  with  the  normal  afflux 
from  the  auricle  filling  the  ventricle  abnormally  full;  it  becomes 
dilated,  and  thus  the  tips  of  the  mitral  valves,  even  before  the  begin- 
ning of  the  systole,  are  somewhat  pushed  up.  When  the  systole  takes 
place,  there  is  then  only  a  moderate  increase  in  its  tension." 

Diminished  intensity  of  the  first  sound  in  the  tricuspid  area  is 
noted  in  all  those  conditions  mentioned  before  which  affect  the 


AUSCULTATION  273 

strength  of  the  ventricular  muscle,  such  as  the  pyrexial  states,  de- 
generative changes,  obesity,  various  forms  of  chronic  auto-intoxica- 
tion and  malassimilation,  etc. 

(5)  ACCENTUATION  OF  THE  DIASTOLIC  SOUND.  The  Aortic 
Sound. — Xormally  the  second  sound  is  better  heard  at  the  base  than 
at  the  apex ;  consequently,  whenever  it  is  well  or  loudly  heard  over  or 
near  the  latter  region,  the  first  sound  at  the  same  time  not  being 
weakened,  it  means  accentuation.  Obviously,  intensification  of  the 
aortic  second  sound  indicates  a  degree  of  recoil  pressure  within  the 
aorta  causing  the  valve  leaflets  to  close  with  increased  tension  and 
suddenness.  As,  in  middle  life,  the  aortic  second  sound  is  but  a 
trifle  louder  than  the  pulmonic,  it  is  difficult  to  detect  slight  accentu- 
ation of  the  former  because  of  the  lack  of  any  standard  of  invariable 
intensity.  In  the  words  of  Balfour :  "  It  is  only  when  some  distinct 
quality  is  superadded,  such  as  that  which  is  very  fairly  expressed  by 
the  word  booming,  that  we  can  speak  with  perfect  confidence  .  .  . 
that  whenever  an  aortic  sound  is  heard  possessing  this  quality,  some 
degree  of  dilation  of  the  ascending  aorta  is  always  present,  or  if  the 
aorta  be  not  found  actually  dilated  after  death,  it  is  flabby  and  dilata- 
ble— the  sine  qua  non  for  the  production  of  an  accentuated  aortic 
sound  being  the  presence  in  the  ascending  aorta  of  a  column  of  blood 
greater  and  heavier  than  usual." 

Increased  intensky  of  the  aortic  sound  from  increased  tension  of 
the  aortic  circulation  may  be  due  also  to  the  following  conditions: 
those  which  cause  increased  peripheral  resistance  to  the  blood  onflow, 
such  as  athcroma  of  the  aorta,  especially  arteriosclerosis,  chronic 
arterial  hypertension  (Cook),  and  chronic  interstitial  nephritis;  aortic 
aneurism,  and  the  cardiac  hypertrophy  and  dilation  which  usually 
accompanies  and  results  from  the  preceding.  Again,  we  may  have 
accentuated  aortic  sound  without  permanent  changes  in  the  arteries, 
and  thus  the  transient  increased  pressure  within  the  aorta  pointing 
to  the  beginning  of  disease,  as  in  association  with  chill,  epilepsy, 
nervous  shock,  serous  membrane  inflammations,  acute  infections,  and 
at  the  onset  of  complications,  as  of  nephritis  in  scarlatina. 

Accentuated  aortic  second  sound  has  a  loud  clicking  quality,  some- 
times almost  metallic,  or  it  may  be  low  pitched  and  resonant,  as  in 
dilation  of  the  aorta.  So  sharp  is  the  accentuation  frequently  in 
cases  of  aortic  aneurism  that  it  becomes  transmissible  as  the  "  dias- 
tolic  shock  "  to  the  palpating  hand.  If  marked  weakening  and  dila- 
tion of  the  left  ventricle — "  heart  failure  " — occurs,  the  accentuation 
subsides  and  disappears  promptly. 
20 


274  PHYSICAL    DIAGNOSIS 

As  the  normal  aortic  second  sound  is  distinctly  louder  in  those 
past  forty  or  forty-five  years  of  age,  and  decidedly  so  in  those  of 
sixty  and  more  years,  care  should  be  observed  not  to  nlis judge  a 
pathologic  condition  when  there  is  none  simply  because  accentuation 
is  discovered  in  individuals  at  this  period  of  life.  The  student  should 
be  reminded,  also,  of  the  possibility  of  an  abnormally  loud  aortic 
sound  resulting  from  exposure  of  the  first  part  of  the  arch  of  the 
aorta  by  a  retracted  right  lung,  or  from  the  consolidation  of  the 
portion  of  lung,  or  a  cavity  adjacent  to  it. 

(6)  WEAKENING  OF  THE  AORTIC  SOUND. — Diminished  intensity 
of  the  aortic  second  sound  indicates  weakness  of  the  heart,  temporary, 
as  in  the  course  of  infectious  and  exhausting  fevers;  permanent,  as 
from  the  various  causes  of  chronic  myocardial  degeneration,  meta- 
bolic, alcoholic,  toxic,  and  the  like.    In  these  cases  the  systolic  sound 
is  simultaneously  weakened.     Intra-aortic  blood  pressure  may  be  low, 
as  indicated  by  feeble  aortic  sound,  because  of  relaxation  of  the  periph- 
eral arteries,  or  because  of  a  diminished  volume  of  blood  thrown  into 
the  aorta,  as  in  the   stenotic  or  obstructive  lesions   of  the  mitral 
and  aortic  valves.     In  the  former  of  these  valvular  defects — mitral 
stenosis — the   flow   of   blood   to   the  left   ventricle  being   impeded, 
each    systole    propels    a    diminished   volume;    in    the    latter — aortic 
stenosis — the    intraventricular    volume    of    blood    may    be    normal, 
or  even  slightly  increased,  but  its  freedom  and   fulness   of  onflow 
is   restricted.      Mitral   regurgitation    similarly    lessens   aortic    blood 
volume. 

Weakened  intensity  of  this  sound  may  result  also  from  loss  of 
blood  mass,  as  in  severe  hemorrhages,  colliquative  diarrheas,  anemia, 
etc.,  and  from  such  changes  in  the  valves  themselves  as  cause  loss 
of  flexibility,  from  swelling,  thickening,  and  distortion,  the  leaflets 
being  unable  to  recoil  with  any  acoustic  intensity. 

Finally,  in  some  cases  of  aortic  insufficiency  the  defect  is  so  great 
as  to  totally  obscure  the  sound  of  imperfect  closure,  nothing  but  the 
soft  swish  of  the  regurgitating  current  of  blood  being  heard  at  the 
beginning  of  diastole. 

(7)  ACCENTUATION  OF  THE  PULMONIC  SOUND. — This  occurs  with 
any  pulmonary  or  cardiac  disease  which  increases  blood  pressure  within 
the  pulmonary  circuit  by  obstruction  to  the  blood  flow  in  the  arteries, 
veins,  or  capillaries.     Years  ago  Skoda  pointed  out  that  persistent 
accentuation  of  the  pulmonary  second  sound  was  an  important  aid 
in  the  diagnosis  of  lesions  of  the  mitral  valve,  although,  if  congestive 
or  emphysematous  disease  of  the  lungs  can  be  excluded,  this  physical 


AUSCULTATION  275 

sign  may  be  indicative  of  any  other  cardiac  valvular  lesion  at  some 
stage  of  its  development  or  secondary  influence. 

A  contributory  and  concomitant  factor  in  the  production  of  ac- 
centuation of  the  pulmonic  second  sound  is,  of  course,  hypertrophy 
of  the  right  ventricle,  since  this  invariably  results  from  a  damming 
back  of  blood  in  the  lungs,  as  in  stenosis  or  insufficiency  of  the  mitral 
orifice,  or  from  obstructive  pulmonary  disease,  such  as  emphysema, 
chronic  tuberculosis,  and  chronic  fibroid  pneumonia  (phthisis).  So 
long  as  the  accentuation  is  maintained  to  a  degree  of  intensity  equal 
to  or  greater  than  that  of  the  aortic  sound,  it  is  a  sign  of  competency 
of  the  right  ventricular  muscle,  and  the  absence  of  insufficiency  with 
regurgitation  at  the  tricuspid  orifice. 

The  last  point  mentioned  is  of  extreme  diagnostic  importance  in 
cases  of  acute  lobar  pneumonia,  where  the  danger  of  failure  of  the 
right  heart  is  so  constant  and  arises  so  suddenly.  In  emphysema, 
notwithstanding  the  dilated  lung  overlaps  the  heart  to  a  greater  ex- 
tent than  normal,  the  accentuated  pulmonary  second  sound  may  usu- 
ally be  heard  most  distinctly  of  all  the  valve  sounds.  In  mitral 
obstruction  the  pulmonary  blood  pressure  is  heightened  on  account 
of  the  overfilled  left  auricle  and  pulmonary  veins,  thus  increasing 
the  resistance  in  the  pulmonary  arteries  and  right  ventricle,  while 
in  mitral  insufficiency  the  back  flow  of  a  portion  of  blood  with  each 
systole,  meeting  that  coming  from  the  lungs,  in  time  makes  itself 
felt  in  the  pulmonary  artery,  with  consequent  accentuation  of  the 
pulmonary  valve  closure. 

In  not  a  few  individuals  of  sedentary  habits,  an  accentuated  pul- 
monic second  sound  may  be  apparent  only,  and  due  to  a  comparative 
weakness  of  the  aortic  second  sound  because  of  flabby,  feeble  intra- 
aortic  blood  pressure  (Hardy). 

(8)  WEAKENED  PULMONIC  SOUND. — This  is  especially  important 
in  its  relation  to  previous  accentuation,  in  the  course  of  valvular 
disease  of  the  heart,  as  a  matter  of  prognosis.  The  latter  is  unfavor- 
able or  bad  in  direct  proportion  to  the  degree  of  diminution  of 
intensity  of  an  accentuated  pulmonary  second  sound.  It  means 
that  the  previously  compensating,  hypertrophied  right  ventricle  is 
giving  way  to  a  flabby  weakening,  with  dilation,  and  probably  re- 
gurgitation  at  the  tricuspid  orifice,  because  of  the  dilation  and  rela- 
tive insufficiency  of  the  valve  cusps.  As  a  sign  of  imminent  danger 
of  failure  of  the  right  ventricle  in  that  treacherous  disease — pneu- 
monia— weakening  of  the  accentuated  pulmonic  sound  is  of  first 
importance,  although,  as  will  be  pointed  out  shortly,  the  change 


276  PHYSICAL    DIAGNOSIS 

in  pitch  of  this  sound  may  be  prompter  evidence  than  change  of 
intensity. 

Pitch. — Changes  in  the  pitch  of  the  first  or  second  heart  sounds 
go  hand  in  hand,  practically,  with  those  pertaining  to  quality.  Thus, 
the  more  the  first  sound  becomes  like  the  second  in  quality  the  higher 
in  pitch  it  becomes,  naturally,  and  the  weaker  the  ventricular  muscle 
is  indicated  thereby. 

It  is  with  the  pitch  of  the  second  sound,  however,  that  more 
practical  value  is  connected.  As  intimated  before,  this  attribute,  as 
an  independent  and  correlated  factor,  has  been  neglected  as  regards 
the  second  sound  of  the  heart.  At  the  outset,  the  qualifying  terms 
of  pitch  should  be  used  with  discrimination,  the  word  accentuation 
(intensity)  not  being  synonymous  with  elevation  (pitch) ;  in  fact,  the 
reverse  being  true,  as  a  rule,  the  louder  sound  being  lower  in  pitch, 
other  things  being  equal.  In  the  careful  auscultation  of  more  than 
500  normal,  healthy  adult  individuals,  I  found  that  approximately 
eighty  per  cent  had  a  slightly  higher  pitch  of  the  aortic  as  compared 
with  the  pulmonary  valve  sound.  Hence,  any  rise  in  pitch  equaling  or 
exceeding  that  of  the  aortic  second  sound  may  be  considered  as  signifi- 
cant of  increase  of  tension  within  the  pulmonary  artery,  due  either 
to  resistance  of  the  blood-flow  in  the  left  heart  or  to  some  congestive 
condition  in  the  lung,  leading  to  or  already  accompanying  incipient 
hypertrophy  of  the  right  ventricle.  This  sign  appears  before  accentu- 
ated loudness  is  decidedly  noticed,  in  most  instances.  Even  later,  as 
the  cause  of  the  intravascular  increased  pressure  is  maintained  and 
continued,  with  accentuation  of  loudness,  the  pitch  also  being  elevated 
is  no  contradiction  to  the  physical  law  of  inverse  ratio  of  intensity 
to  pitch,  but  simply  shows  that  the  law  as  to  pitch  supervenes,  namely, 
the  greater  the  tension  the  higher  the  pitch. 

From  which  it  will  be  seen  that,  given  a  seriously  ill  case  of  acute 
lobar  pneumonia,  for  example,  with  marked  elevation  of  pulmonic 
sound  pitch,  indicating  that  the  right  ventricle  is  meeting  the  tre- 
mendous demands  made  upon  it  by  the  consolidated  lung  area,  the 
earliest  and  slightest  perceptible  depression  of  that  pitch  must  be  no 
less  than  the  veriest  danger  signal  of  beginning  failure  of  that  muscle. 
If  the  lowering  of  pitch  be  but  moderate,  to  a  degree  corresponding 
with  the  aortic,  the  partial  yielding  of  the  ventricular  walls  which  this 
signifies  may  fall  within  the  prognostic  pale  of  hope,  notwithstanding 
a  justifiable  anxiety ;  whereas,  a  depression  of  pitch  to  the  point  which 
is  consistent  with  health  means,  in  this  case,  a  feeble,  flabby,  fatal,  un- 
conditional surrender  to  the  resisting  forces  and  poisoning  influences. 


AUSCULTATION  277 

Likewise,  the  incipient  development  of  emphysema — a  type  of  the 
chronic  pulmonary  disease — in  cases  of  recurrent  attacks  of  bron- 
chitis (the  "winter  cough  "  of  old  people),  and  paroxysms  of  asthma, 
may  be  recognized  in  gradual  and  persistent  elevations  of  the  pitch 
of  the  pulmonary  valve  sound,  even  before  any  alterations  of  the 
percussion  and  breath  sounds  over  the  lungs  may  be  observed.  Here 
the  rise  of  tension  within  the  pulmonary  circulation  is  explained  as 
due  to  the  resistance  to  the  onflow  of  blood  within  the  myriads  of 
pulmonary  capillaries  whose  caliber  becomes  diminished  by  the  over- 
stretching to  which  they  are  subjected  as  the  containing  alveolar 
walls  become  dilated — emphysematous — and,  perhaps,  also  thickened 
by  some  fibrosis  from  the  chronic  irritation  of  the  causative  affections. 
Dependence  upon  the  element  of  pitch  may  be  a  necessity  as  well  as 
an  independent  factor  in  this  matter  of  diagnosis,  since  mere  accentu- 
ation of  the  pulmonic  second  sound  may  be  obscured  by  the  buffer, 
non-conducting  effect  of  enlarging  and  border-extending  lung.  A 
lowering  of  the  pitch  of  the  pulmonic  sound  in  evident  emphysema 
would  indicate,  therefore,  weakening  of  the  right  ventricle  under  the 
persistent  and  progressive  strain,  and  the  impending  congestive  dis- 
orders which  are  entailed  thereby. 

Altered  Rhythm  of  Cardiac  Sounds. — Arrhythmia  may  be  due  to 
(1)  alterations  in  the  relative  length  of  the  xilences  between  the  two 
heart  sounds,  or  to  (2)  a  doubling  or  reduplication  of  the  sounds. 

(1)  FETAL  RHYTHM   on  EMBRYOCARDIA. — Whenever  the  triple 
rhythm  of  the  normally  acting  heart — the  "  one-two-three,"  or  3:4. 
or  waltz  time  in  music — corresponding  to  the  first  and  second  sounds 
and  the  diastolic  or  long  pause,  is  disturbed  so  that  the  latter  element 
is  shortened,  then  the  silences  are  equal  in  length,  and  the  two  sounds 
follow  each  other  as  regularly  as  the  ticking  of  a  clock.     The  first 
sound  also  resembles  the  second  sound  so  closely  that  the  tick-tack 
has  been  likened  to  the  equality  of  the  fetal  heart-beats;  hence  the 
term  embryocardia.     The  rhythm  is  then  changed  to  the  2:4  time 
(Butler).     The  heart  action  is  at  the  same  time  much  accelerated 
and  decidedly  weakened.     Indeed,  embryocardial  rhythm  is  directly 
indicative   of   a   serious   weakening  of  the   cardiac  muscle,  such  as 
occurs  in  the  later  stages  of  the  acute  infectious  fevers,  in  typhoid 
especially,  in  chronic  myocardial  degeneration,  loss  of  compensation 
in  valvular  heart  disease,  conditions  of  collapse,  and  in  exophthalmic 
goiter. 

(2)  PROLONGATION  OF  THE  DIASTOLIC  SILENCE. — This  is  usually 
accompanied  with  accentuation  of  both  cardiac  sounds,  the  long  pause 


278 


PHYSICAL   DIAGNOSIS 


occupying  as  much  rhythmical  time  as  the  third  and  fourth  beats  of 
4 :  4  musical  time.  Prolonged  diastolic  pause  indicates  either  the  ex- 
cessive or  cumulative  action  of  digitalis,  or  the  strenuous,  "  spasmodic 


Normal 
^Time 

n 

— 

T 

— 

— 

Embryocardia 


Prolonged 
Second 
Silence 
%Time 

1 

— 

r 

T. 

_ 

L 

FIG.  56. — DIAGRAM  REPRESENTING  Two  VARIATIONS   FROM  THE  NORMAL  CARDIAC 
RHYTHM.     To  be  read  from  left  to  right.     (Butler.) 

effort  of  an  overworked,  weak,  or  degenerated  heart  to  continue  its 
labors." 

(3)  CANTER  OR  GALLOP  EHYTHM. — The  auscultator  recognizes  a 
third  interpolated  or  accidental  sound  as  well  as  the  two  regular 
cardiac  sounds,  the  three  sounds  simulating  the  hoof  strokes  of  a 
galloping  horse;  hence  the  term  applied  to  this  form  of  arrhythmia. 
The  extra  sound  occurs  in  the  long  silence ;  in  some  instances,  imme- 
diately after  the  normal  second  sound,  which  may  be  accentuated  or 
not,  or  in  the  middle  of  diastole;  in  other  cases,  near  the  end  of 
diastole,  or  just  before  the  first  sound — at  presystole.  The  sounds  are 
usually  similar,  short,  and  partly  ringing,  or  the  third  sound  may  be 
of  a  different  character,  like  the  clack  of  a  cantering  horse,  which 
led  the  Frenchman,  Bouillaud,  to  first  apply  the  descriptive  phrase, 


AUSCULTATION  279 

bruit  de  galop.  The  third  sound  may  resemble  either  the  first  or 
second  sound,  and  may  thus  seem  to  be  a  reduplication  of  either, 
respectively. 

The  gallop  rhythm  generally  indicates  a  grave,  often  fatal,  condi- 
tion of  cardiac  weakness,  where  the  sign  is  persistent.  It  means  that 
there  is  a  dangerous  abnormal  increase  in  the  intraventricular  blood 
pressure,  and  consequently  of  the  tension  of  the  ventricular  wall. 
The  more  rapid  the  gallop  rhythm  the  worse  the  prognosis.  Accord- 
ing to  Babcock,  a  rapid  gallop  rhythm  differs  from  a  slow,  cantering 
one  in  that  the  accent  falls  most  sharply  on  the  first  or  third  instead 
of  the  middle  one  of  the  three  sounds  in  the  former  case. 

This  variety  of  arrhythmia  is  an  important  danger  signal  in  such 
diseases  as  chronic  interstitial  nephritis,  arteriosclerosis,  especially  in 
the  hypertrophic  dilation  of  the  ventricles  with  loss  of  compensation ; 
in  myocardial  degeneration  from  various  causes;  in  adherent  pericar- 
dium with  dilation  of  the  heart;  and  sometimes  in  cases  of  severe 
anemia.  It  is  a  very  grave  sign  occurring  in  the  course  of  certain 
acute  infectious  diseases,  as  typhoid  fever,  lobar  pneumonia,  and  acute 
articular  rheumatism,  and  may  be  the  first  sign  of  beginning  paralysis 
of  the  heart  in  diphtheria.  It  is  heard  more  distinctly  over  the  right 
ventricle  in  cardiac  and  pulmonary  diseases  which  cause  dilation  of 
this  chamber.  Thus,  the  overdistention  may  result  from  mitral  steno- 
sis, advanced  mitral  regurgitation,  and  pulmonary  emphysema. 

(4)  REDUPLICATION  OF  THE  HEART  SOUNDS. — When  permanent, 
doubling  of  the  first  or  second  sound  is  practically  always  pathologic. 
Probably  in  the  majority  of  instances  the  gallop  rhythm  is  really  due 
to  a  reduplication  of  either  one  of  the  systolic  or  diastolic  sounds. 

Reduplication  of  the  Diastolic  Sounds. — Obviously,  this  is  due  to 
broken  synchronism  of  the  closing  action  of  the  cusps  of  either  the 
aortic  or  pulmonic  valves.  As  intimated  before,  reduplication  may 
be  transient  or  physiologic,  and  when  not  so  its  diagnostic  value 
may  be  quite  subordinate  to  other  associated  physical  signs.  It  is 
produced  directly  by  an  abnormal  increase  of  pressure  within  the 
peripheral  or  pulmonary  circulation,  thus  throwing  added  strain  upon 
the  left  or  right  ventricle,  respectively.  The  interval  between  the 
doubled  sounds  is  usually  extremely  short,  so  that  they  may  be  said 
to  run  together,  whereas  in  the  canter  rhythm,  a  distinct,  complete 
interval  is  demonstrable.  In  doubtful  cases  of  doubling  of  the  dias- 
tolic sounds,  the  phenomenon  may  be  elicited  better  by  noting  it  at 
the  end  of  inspiration  and  the  beginning  of  expiration. 

Owing  to  the  normally  greater  pressure  Within  the  aorta  as  com- 


nn of 


280  PHYSICAL    DIAGNOSIS 

pared  to  that  within  the  pulmonary  artery,  the  aortic  valve  closes  a 
fraction  of  a  second  earlier  than  the  pulmonic,  but  this  is  not  appre- 
ciable to  the  ear.  In  reduplication,  the  second  sound  may  be  illus- 
trated by  pronouncing  the  syllables  lub-tupptup  instead  of  the  normal 
lub-tup,  the  first  of  the  two  diastolic  sounds  being  accentuated  some- 
what, and  often  slightly  elevated  in  pitch.  Balfour  likens  the  redu- 
plicated sound  to  that  made  by  "  a  hammer  which  strikes  the  anvil, 
rebounds,  and  strikes  again,  remaining  motionless." 

The  frequent  association  of  reduplicated  second  sound  with  mil  ml 
stenosis  makes  this  sign  have  some  diagnostic  corroborative  value. 

The  tension  in  the  pulmonary  artery 
is  raised  to  such  a  degree  because  of 
the  mass  of  blood  held  back  by  the 
mitral    obstruction,    so    that,    as    ex- 
FIG.  57.-A.  Normal  first  and  sec-     Pained  by  Ceradini,  the  blood  pres- 
ond  sounds.     B.  Reduplicated     sure  is  sufficient  to  separate  the  sound 

and  accentuated   second  sound.         f      j  t   t,  d      f  ^ 

(Gibson  and  Russell.) 

tole  from  that  produced  by  the  ar- 
terial systole — in  health,  these  two  events  being  heard  as  one  diastolic 
sound.  Next  to  mitral  stenosis,  the  most  frequent  causes  of  redu- 
plication of  the  diastolic  sound,  from  exaggerated  pressure  in  the  pul- 
monary circulation,  are  the  following:  emphysema,  tuberculosis,  and 
bronchopncumonitis ;  hypertrophic  dilation  of  the  right  ventricle. 

Reduplication  of  the  second  sound  is  most  clearly  heard  near  the 
middle  of  the  sternum,,  or  at  the  left  border  of  the  sternum  between 
the  third  and  fifth  costal  cartilages;  in  cases  of  mitral  stenosis  it  is 
often  heard  at  the  apex.  If  the  cardiac  action  becomes  rapid,  the 
reduplication  may  not  be  distinguishable,  or  may  persist  as  a  short 
murmur. 

Apparent  or  false  doubling  of  the  second  sound  has  been  pointed 
out  by  Sansom  and  other  English  clinicians.  This  phenomenon  is 
also  peculiar  to  cases  of  mitral  stenosis,  and  may  be  heard  at  tin- 
apex,  while  at  the  base  accentuation  of  the  second  sound  without 
reduplication  may  be  heard.  This  simulated  doubling  frequently 
passes  into  a  distinct  diastolic  murmur.  Its  explanation  is  most 
plausibly  given  by  Sansom.  He  holds  that  the  normal  physiologic 
second  sound  is  followed  by  an  interpolated  third  sound  due  to  the 
sudden  tension  of  the  mitral  curtain  from  the  impact  of  the  blood 
coming  from  the  auricle  to  the  ventricle,  at  the  beginning  of  diastole. 
It  will  be  recalled  that  the  blood  is  under  considerable  pressure  in  the 
left  auricle  in  cases  of  mitral  obstruction,  and  its  sudden  release  into 


AUSCULTATION  281 

the  dilating  ventricle  comes  with  a  decided  shock  against  the  mitral 
cusps  immediately  after  the  pulmonic  valve  closure. 

Eeduplication  of  the  diastolic  sound  due  to  increased  tension 
within  the  aorta  is  less  commonly  met  with,  as  in  advanced  cases  of 
chronic  arterial  hypertension,  with  or  without  arteriosclerosis,  and  in 
chronic  Bright's  disease. 

Reduplication  of  the  Systolic  Sounds. — Pathologic  douhling  of  the 
first  sound  is  comparatively  rare,  more  apparent  than  real,  and  may 
be  an  incipient  presystolic  murmur  preceding  the  actual  first  sound 
by  an  extremely  short  interval.  The  doubling  is  not  due  to  a 
synchronous  contraction  of  the  ventricles,  but  most  probably  to  non- 
synchronous  closure  of  the  mitral  and  tricuspid  valves,  or  to  non-syn- 
chronous tension  of  the  cusps  of  these  valves. 

Under  any  explanation,  the  physical  sign  indicates  excessive  pres- 
sure within  the  ventricle — usually  dangerously  dilated — over  which 
the  doubling  is  best  heard :  over  the  right  ventricle  in  mitral  lesions 
and  obstructive  pulmonary  diseases,  over  the  left  ventricle  in  chronic 
nephritis,  especially,  with  increased  resistance  in  the  peripheral  ar- 
teries and  cardiac  hypertrophy. 

(5)  IRREGULARITY. — When  the  cardiac  sounds  succeed  each  other 
with  a  variety  of  divergences  as  to  rapidity,  quality,  loudness,  and 
relative  lengths  of  the  intervening  silences  in  several  or  all  of  these 
characters,  the  simple  term  irregularity  is  applied  to  them.     Thus, 
uniformity  of  rhythm  may  be  broken  by  a  number  of  combinations 
of  these  changed  attributes,  the  most  common,  however,  being  those 
of   strength,   duration,   and  frequency,  one   or  two  distinct   sounds 
rapidly  following  each  other  with  short  intervals,  to  be  followed  in 
turn  by  a  longer  silence  and  a  few  weak,  abortive  sounds;  or  these 
features  may  be  inverted,  etc.     The  gallop  rhythm  is  really  a  form 
of   irregularity.      Gravity  of  myocardial   condition  is   indicated   by 
irregularity  of  the  cardiac  sounds;  this  is  especially  marked  in  cases 
of  mitral  disease  with  failure  of  compensation,  in  fatty  heart,  and  in 
severe  debility  during  or  following  acute  toxemic  febrile  diseases. 

(6)  INTERMITTENT. — This  may  occur  either  as  a  subdued  and 
abortive,  or  as  a  totally  suppressed  sound  at  certain  intervals — a  sort 
of  regular  irregularity.    The  intermissions  may  be  one  in  five,  seven, 
ten,  twelve,  or  eighteen  beats,  and  so  on,  as  the  case  may  be.     The 
cause  is  often  obscure,  and  as  often  is  unconnected  with  any  evident 
pathologic  condition  of  the  heart.     It  may  be  a  temperamental  pe- 
culiarity, a  neurosis,  or  a  manifestation  of  a  dyspeptic,  gouty,  auto- 
toxic,  or  nephritic  affection. 


CHAPTER    XIII 
AUSCULTATION  (Concluded) 

ADVENTITIOUS    SOUNDS    OR    CARDIAC    MURMURS 

THE  abnormal  or  adventitious  sounds  produced  under  the  pre- 
cordial  area  may  originate  within  the  heart,  and  are  then  termed 
endocardial ;  or  they  may  come  from  the  pericardial  sac,  and  are  thus 
known  as  exocardial  or  pericardial.  Pleuropericardial  and  cardiopul- 
monary  sounds  may  also  be  heard  in  the  region  of  the  heart  over- 
lapped by  lung  or  adjacent  thereto.  Although  the  word  murmurs  is 
used  by  some  systematic  writers  to  embrace  all  adventitious  sounds 
heard  in  connection  with  the  heart's  action,  practically  it  is  limited 
to  include  only  those  which  are  endocardial ;  that  is,  produced  within 
the  cardiac  chambers  and  beginnings  of  the  great  vessels. 

(A)   CLASSIFICATION  OF  MURMURS 

The  endocardial  murmurs  are  subdivided  into  (1)  organic  or 
structural,  and  (2)  functional  or  dynamic,  kemic  or  anemic.  The 
latter  class  are  also  designated  frequently  as  inorganic  and  accidental ; 
they  are  associated  with  disorders,  more  or  less  temporary,  affecting 
the  quality  or  composition  of  the  blood,  such  as  the  essential  and 
symptomatic  anemias,  debilitating  chronic  diseases,  etc.,  or  with  dis- 
turbances of  cardiac  innervation. 

The  organic  endocardial  murmurs  are  valvular  in  origin;  that  is, 
they  are  due  to  some  structural  defect,  distortion,  obstruction,  or  other 
pathologic  alteration  of  the  cardiac  valves  or  orifices.  While,  there- 
fore, murmurs  are  nearly  always  indicative  of  certain  valvular  changes, 
yet,  in  the  words  of  Balfour,  "  their  evidence  must  be  accepted  with 
caution,  first,  because  we  may  have  murmurs  of  exocardiac  origin 
which  simulate  very  closely  those  of  valvular  origin,  and,  second, 
because  murmurs  truly  of  valvular  origin  may  disappear  temporarily 
or  permanently.  Thus,  we  may  have  a  murmur  apparently  of  valvu- 
lar origin  which  is  really  exocardiac ;  second,  we  may  have  a  murmur 
truly  of  valvular  origin,  yet  without  valvular  lesion,  which  may  dis- 
282 


AUSCULTATION  283 

appear,  leaving  the  heart  uninjured;  and,  lastly,  we  may  have  a 
murmur  truly  of  valvular  origin  which  may  disappear  temporarily  or 
permanently,  the  valvular  lesion  still  continuing."  Hence,  a  murmur 
must  never  be  considered  a  pathognomonic  factor  in  physical  diag- 
nosis, but  always  correlated  and  estimated  in  connection  with  the 
results  obtained  by  inspection,  palpation,  and  percussion,  as  well  as 
the  auscultation  of  the  normal  heart  sounds. 

The  abnormal  sounds  of  pericardial  origin  are  usually  termed 
friction  sounds;  likewise  those  of  pleuropericardial  production.  The 
cardiopulmonary  sounds  are  designated  as  murmurs,  probably  because 
of  their  softer  quality,  similar  to  the  endocardial  murmurs  commonly 
encountered. 

Aneurismal  murmurs,  or  bruits,  are  usually  heard  over  the  aortic 
arch  and  at  the  base  of  the  heart. 

(B)   MODE  OF  PRODUCTION  OF  MURMURS 

The  physical  explanation  of  murmurs  may  be  rendered  more  lucid 
by  the  appended  preliminary  remarks  relating  to  the  factors  involved. 
In  the  first  place,  it  should  be  mentioned  that  formerly  it  was  held 
that  endocardial  murmurs  resulted  directly  from  the  friction  caused 
by  the  passage  of  blood  over  roughened  surfaces  and  constrictions  of 
the  endocardium.  The  only  tenable  view,  that  now  held,  attributes  the 
production  of  murmurs  to  eddies  or  currents  of  blood  set  up  by  ob- 
structions at  the  orifices  or  leakages  at  the  valves,  these  disturbances 
in  the  blood  flow  producing  the  sound  vibrations  which  are  conducted 
to  the  surface  of  the  chest.  Normally,  the  blood  flows  through  the 
valvular  orifices,  in  the  physiologic  direction  and  rhythm,  without 
sound. 

(1)  However,  it  is  with  the  blood  as  with  any  other  liquid  under 
a  certain  degree  of  pressure,  namely,  that  whenever  it  passes  or  is 
forced  through  a  constriction  of  its  containing  tube  into  a  wider 
portion  beyond,  audible  vibrations  are  generated  by  the  eddies  and 
currents  thus  set  up.  These  secondary  currents  are  the  "  fluid  veins  " 
of  the  physicists.  In  the  diseased  human  heart  there  may  be  a  nar- 
rowed orifice  leading  into  a  larger  normal  or  dilated  cavity;  or  the 
orifice  may  remain  normal  in  caliber,  but  relatively  narrowed  because 
of  marked  dilation  of  the  cavity.  In  either  case,  the  fluid  veins  set 
up,  and  their  accompanying  vibrations  follow  the  main  current,  pro- 
ducing so-called  direct  or  onward  murmurs.  These  are  the  murmurs 
of  stenosis  or  obstruction. 


284  PHYSICAL   DIAGNOSIS 

If,  on  the  other  hand,  the  valvular  mechanism  is  so  altered  that 
perfect  closure  is  prevented  when  physiologically  it  should  he  accom- 
plished, a  part  of  the  blood  regurgitates  through  the  small  aperture 
into  the  chamber  from  which  it  came  previously,  as  an  opposing  or 
backward  fluid  vein.  The  vibrations  produced  are  doubtless  due 
partly,  also,  to  the  oblique  impact  of  the  blood  stream  against  the 
beveled  projecting  edges  of  the  incompetent  leaflets  (Davidson). 
This  valvular  insufficiency,  therefore,  gives  rise  to  indirect,  backward, 
or  regurgitating  murmurs.  According  to  Geigel,  who  used  mathe- 
matical formulae  bearing  upon  the  pitch  of  murmurs  to  prove  his 
point,  these  are  rationally  explicable  only  on  the  basis  of  transverse 
vibrations  of  the  cardiac  or  of  the  vascular  walls  surrounding  the 
disturbed  blood  stream. 

(2)  The  strength  or  loudness  or  audibility  of  endocardial  mur- 
murs will  depend  upon  the  force  and  rapidity  of  the  blood  flow.    Ven- 
tricular weakness  may  cause  the  previously  distinct  murmurs  of  a 
hypertrophied    heart    to   diminish    in    intensity,   or    even    disappear 
entirely. 

(3)  That  a  lowered  specific  gravity  and  consequent  thinner  state 
of  the  blood  permits  it  to  be  thrown  into  vibration  by  valvular  defects 
more  readily  is  quite  probable.     In  fact,  all  three  of  these  physical 
factors  may  be  present  in   varying  degrees  in   the  production  and 
modification  of  organic  murmurs. 

Pathologic  Conditions. — The  principal  local  lesions  which  are  re- 
sponsible for  the  production  of  murmurs  at  the  valve  orifices  are  the 
results  of  endocarditis,  which  in  turn,  in  perhaps  seventy  per  cent  of 
the  cases,  is  caused  by  acute  articular  (inflammatory)  rheumatism', 
the  other  three  etiologic  disorders  of  the  "  big  four  isms  " — as  I  have 
often  designated  them  to  students — are  alcoholism,  syphilism,  and 
athleticism.  Among  the  special  changes  are  the  following:  Adhesion 
of  the  flaps  of  a  valve  and  shortening  of  the  chordae  tendinea?;  cica- 
tricial  narrowing  and  constriction  of  the  arterial  or  auriculoventricu- 
lar  orifices;  projection  into  the  lumen  of  the  aorta  or  pulmonary 
artery,  etc.,  of  vegetations  or  calcareous  plates  and  the  like  upon 
the  walls  or  valves;  disease  (degenerative)  of  the  papillary  muscles; 
loose  portions  of  ruptured  valve  cusps,  bands,  and  strings  vibrating 
in  the  blood  stream ;  vascular  dilations,  especially  aneurismal. 

To  summarize,  the  main  physical  alterations  productive  of  organic 
endocardial  murmurs  are  as  follows: 

(1)  Insufficiency,  or  incompetency,  causing  regurgitation  of  blood 
when  the  valves  fail  to  close  at  the  physiologic  time. 


AUSCULTATION  285 

(2)  Stenosis  (constriction),  or  obstruction  at  the  orifices,  inter- 
fering with  the  free  and  full  flow  of  blood  when  the  valves  should 
normally  be  open. 

(3)  Relative  insufficiency  at  a  valve  (especially  the  mitral  or  tri- 
cuspid)  orifice,  because  of  dilation  of  the  heart  chamber  (weakening 
of  the  myocardium)   containing  it,  the  simultaneous  dilation  of  the 
orifice  causing  improper  closure  of  the  curtains,  which  are  unable  to 
meet. 

Murmurs  sometimes  occur  at  non-valvular  orifices,  such  as  an  open 
foramen  ovale  or  perforated  ventricular  septum — congenital,  rare  con- 
ditions. Likewise,  a  patulous  ductus  arteriosus  may  be  the  cause  of 
a  murmur. 

Characteristics. — It  will  be  seen  that  murmurs  may  be  of  several 
varieties ;  they  may  vary  in  causation,  in  combination,  and  in  general 
and  specific  characteristics.  There  may  be  but  one  murmur  present 
with  distinctive  or  obscure  features,  or  two  or  three  at  different  ori- 
fices, perhaps  two  at  one  orifice  (double  lesion).  Hence,  to  state  the 
important  and  significant  facts  about  a  murmur  which  it  is  the  pur- 
pose to  learn  should  come  first,  and  then  a  seriatim  consideration  of 
these  in  detail. 

The  points  to  be  noted  about  a  murmur  are  the  following: 

(1)  Its  localization  or  area  of  greatest  intensity. 

(2)  Its  time  or  place  in  the  cardiac  cycle. 

(3)  Its  area  of  conduction  and  direction  of  transmission. 

(4)  Its  acoustic  attributes — quality,  intensity,  pitch,  and  dura- 
tion. 

(5)  Its  relation  to  the  normal  sounds  of  the  heart. 

(1)  LOCALIZATION,  OR  THE  POINTS  OF  MAXIMUM  INTENSITY. — 
The  first  step  in  the  diagnosis  of  a  murmur  is  to  localize  it,  and 
thus  determine  the  valve  or  orifice  affected.  This  is  ascertained  by 
finding  its  position  of  maximum  intensity.  The  points  of  greatest 
loudness  correspond,  with  few  exceptions,  to  the  areas  already  de- 
scribed, where  the  respective  valve  sounds  are  best  heard;  that  is, 
mitral  valve  murmurs  are  most  distinctly  heard  at  or  near  the 
apex ;  aortic  murmurs,  at  the  right  second  intercostal .  space,  close 
to  the  sternum;  tricuspid  murmurs,  over  the  lower  part  of  the  ster- 
num; and  pulmonary  valve  murmurs,  at  the  left  second  intercostal 
space,  close  to  the  sternum.  A  murmur  whose  maximum  intensity 
does  not  coincide  with  any  one  of  these  areas  is  probably  not  of 
valvular  origin. 

At  the  aortic  area,  aneurismal  bruit  may  also  be  heard.     To  the 


286 


PHYSICAL    DIAGNOSIS 


pulmonic  area,  other  murmurs  than  those  produced  at  this  valve, 
which  are  rare,  may  be  transmitted,  and  the  accidental  or  hcinic 
murmurs  are  frequently  audible  here  also.  The  tricuspid  urea,  which, 
more  than  any  other,  corresponds  with  the  anatomic  seat  of  the  orifice, 
is  not  infrequently  a  region  where  two  other  valve  murmurs  are 


FIG.  58. — SHOWING  PBECORDIAL,  AREAS.     A,  aortic  area;  P,  pulmonary  area; 
Tt  tricuspid  area;  M,  mitral  area.     (Gibson  and  Russell.) 

distinctly  heard,  namely,  that  of  aortic  insufficiency  and  that  of  mitral 
insufficiency.  The  former,  diastolic  in  rhythm,  is  often  more  plainly 
heard  here  than  directly  over  the  aortic  area,  probably  because  the 
downward  regurgitating  current  of  blood  does  not  gather  audible 
vibrations  so  high  above  the  valve  in  these  cases ;  indeed,  this  murmur 
is  sometimes  as  distinct  in  the  left  fourth  interspace,  near  the  ster- 
num, as  in  the  aortic  area.  A  mitral  regurgitant  murmur  (systolic) 
of  marked  loudness  may  be  audible  in  the  tricuspid  area.  The  tri- 
cuspid regurgitant  murmur  (systolic)  is  the  only  one  of  the  right- 
sided  lesions  which  is  ordinarily  met  with,  and  even  it  is  quite  un- 
common. In  the  mitral  area,  the  aortic  regurgitant  murmur  may 
be  heard  in  some  instances,  because  transmitted  thither.  On  the 
other  hand,  analogously,  the  murmur  of  mitral  insufficiency,  although 
less  frequently,  is  well  heard,  not  at  the  apex  but  near  the  left  base 
of  the  heart — that  is,  in  the  third  interspace,  parasternal  line,  over  the 
dilated  left  auricle,  into  which  the  regurgitating  blood  flows. 


AUSCULTATION  287 

Auscultation  of  the  heart  from  the  rear  is  expedient  in  cases  of 
valvular  affections  at  times,  as  the  greater  the  enlargement  of  the 
right  ventricle  the  more  the  apex  and  left  ventricle  are  pushed  toward 
the  back.  According  to  Libensky,  dorsal  auscultation  is  particularly 
useful  in  differentiating  mitral  from  aortic  insufficiency.  In  the  for- 
mer, with  vague  anterior  signs,  it  commonly  happens  that  the  systolic 
murmur  is  best  heard  at  the  inferior  angle  of  the  left  scapula.  When 
the  aortic  valve  is  involved,  however,  the  dorsal  findings  are  loudest 
at  the  left  supraspinous  fossa,  and  toward  the  right  and  downward 
to  the  third  dorsal  spinous  process. 

(2)  TIME  on  BHYTHM. — By  far  the  majority  of  organic  valvular 
murmurs  may  be  diagnosticated,  that  is,  the  lesions  producing  them 
may  be  pretty  positively  inferred  upon  the  double  basis  of  the  facts 
of  the  area  of  greatest  intensity  and  of  the  time  of  the  murmurs. 
Given  these  two  physical  signs  in  conjunction  with  the  anatomic  and 
physiologic  data  related  thereto,  and  the  pathologic  significance  is 
virtually  a  matter  of  logical  deduction  with  syllogistic  regularity. 
The  determination  of  the  area  of  maximum  loudness  fixes  the  valve 
orifice  affected — the  anatomic  element;  that  of  the  time  during  the 
heart's  cycle  when  the  murmur  is  heard  indicates  what  the  normal 
condition  of  function  should  be  at  that  orifice  at  that  time,  and 
simultaneously  whether  the  abnormality  is  obstructive  or  regurgitant, 
since  it  is  either  one  or  the  other;  and  so  we  have  the  physiologic 
and  pathologic  elements. 

For  diagnostic  purposes,  the  correlation  of  these  elements  may  be 
simplified  and  condensed  by  the  statement  of  two  guiding  principles, 
as  follows: 

(a)  Murmurs  of  insufficiency  or  regurgitation  are  heard  at  that 
moment  or  time  during  the  heart's  cycle  when  the  affected  valves 
ought  normally  to  be  closed',  that  is,  they  are  heard  at  systole  when 
the  auriculoventricular  or  venous  (mitral  and  tri cuspid)  valves  leak, 
and  during  diastole  when  the  arterial  (pulmonic  and  aortic)  valves 
are  affected. 

(&)  Murmurs  of  obstruction  or  stenosis  occur  at  that  time  or  stage 
of  cardiac  action  when  normally  blood  passes  through  the  orifices 
affected;  that  is,  they  are  heard  during  systole  with  disease  at  the 
arterial  openings;  during  diastole,  when  the  auriculoventricular  are 
affected. 

The  clinical  facts  which  thus  justify  and  harmonize  with  these 
physiologic  and  pathologic  principles  are  actually  and  obviously  the 
following : 


288  PHYSICAL    DIAGNOSIS 

The  mitral  regurgitant  murmur  is  systolic;  the  aortic  regurgi- 
tant,  diastolic;  the  aortic  nhstriiriivr  murmur,  systolic;  the  mitral 
stenotic,  diastolic,  or,  as  it  is  commonly  designated,  presystolic,  be- 
cause it  is  best  heard  near  the  end  of  diastole  or  just  before  systole. 

With  similar  lesions  on  the  right  side  of  the  heart,  tricuspid  and 
pulmonary  valve  murmurs  have  the  same  times,  since  the  physiologic 
functions  on  the  two  sides  are  homologous. 

The  mode  of  reasoning  in  the  physical  diagnosis  of  a  murmur 
may  be  put  forth  by  two  examples;  thus,  a  murmur  is  best  heard  at 
or  near  the  apex  (the  mitral  area),  systolic  in  rhythm;  normally, 
the  mitral  valve  should  be  closed  at  this  time;  therefore,  it  must 
leak  (insufficiency)  in  order  to  cause  a  murmur  at  this  time.  Again. 
a  loud  murmur  is  most  audible  in  the  right  second  interspace,  also 
systolic;  the  aortic  valve  is  normally  open,  and  blood  passing  freely 
through  the  orifice  at  that  time;  hence,  there  must  be  some  obstruc- 
tion or  narrowing  at  the  orifice  to  set  up  a  murmur  here  at  this  time. 

Murmurs  are  best  heard  and  timed  by  requesting  the  patient  to 
stop  breathing  for  a  little,  so  as  to  exclude  the  occasional  intervention 
of  the  respiratory  murmur,  which  sometimes  resembles  a  soft  endo- 
cardial  murmur,  and  by  placing  a  finger  upon  the  carotid  impulse, 
which  is  synchronous  with  the  first  or  systolic  sound  of  the  ventricles. 
(The  radial  pulse  cannot  be  employed,  as  it  occurs  shortly  after  sys- 
tole.) In  many  cases  of  very  weak  and  rapid  heart  action,  the  latter 
procedure  may  be  absolutely  necessary  to  time  a  murmur,  as  the  first 
sound  may  be  indistinguishable  from  the  second  by  the  acoustic 
qualities  alone. 

At  this  point  may  be  considered  appropriately  (5)  the  relation 
to  the  normal  sounds  of  the  heart  which  these  various  murmurs  com- 
monly sustain.  The  mitral  systolic  may  quite  replace  the  first  sound, 
or  it  may  alter  and  run  off  from  the  first  sound,  or  distinctly  follow 
this  sound,  in  the  short  silence  between  it  and  the  second  sound  (late 
systolic  murmur).  As  a  systolic  murmur  may  occur  at  any  one  of 
the  four  orifices,  its  localization  should  be  precisely  determined.  To 
repeat,  the  mitral  systolic  murmur  indicates  that  there  is  leakage 
at  this  orifice,  the  cusps  being  too  small  to  close  the  orifice,  oil 
account  of  shrinking,  or  too  stiff  to  admit  of  true  coaptation,  or  the 
myocardium  may  be  degenerated  and  dilated,  so  that  the  cusps  are  too 
small  to  close  the  dilated  opening,  or  the  ventricle  too  weak  to  con- 
tract the  orifice  to  the  natural  size  of  the  valve. 

The  aortic  systolic  murmur  usually  occupies  a  distinct  portion  of 
the  first  sound,  and  of  the  short  interval  between  this  and  the  second 


AUSCULTATION 


289 


sound.  It  does  not  always  mean  that  there  is  actual  narrowing  or 
stenosis  of  the  orifice,  or  even  a  limited  obstruction  by  the  valve; 
it  may  result  from  a  roughening  of  one  or  more  of  the  aortic  cusps,  or 
from  moderate  dilation  of  the  aorta  just  above  the  valvular  region. 
True  obstruction  may  be  due  to  thickened  cusps,  vegetative  or  calcare- 


VENTRIC. 
DIASTO 


AURIC. 
SYST. 

LE 


SYSTOLIC  MURMUR 


nm* 

— 

i 

LDIASTOLIC  MURMUR 

. 

pp* 

PP^ 

Ji 

1                A 

BPRESYSTOLIC  MURMUR 

iL 
t 

T 

^1 

I 

1 

rms  T        SECOND 

SOUND.            SOUND. 

riRSJ              SECOND 
SOUND.           SOUND. 

FIG.  59. — DIAGRAM  SHOWING  THE  THREE  CHRONOLOGICAL  TYPES  OF  MTIRMTJRS  AND 
THEIR  RELATION  TO  THE  SOUNDS  OF  THE  HEART.  The  events  of  the  cardiac  cycle 
are  given  above  for  comparison.  Murmurs  shaded  with  vertical  lines.  To  be 
read  from  left  to  right.  (Butler.) 

ous  growths  on  their  surfaces,  or  to  partial  adhesion  of  the  cusps 
to  one  another. 

The  aortic  regurgitant  murmur  usually  begins  with  and  may  ob- 
literate the  second  sound;  also  occupies  the  greater  part  of  the  dias- 
tolic  silence.  The  lesion  which  frequently  produces  this  murmur  is 
shrinking  and  thickening  of  the  valves.  Vegetations  and  calcareous 
nodules  may  also  cause  leakage  by  preventing  close  contact  of  the 
edges  of  the  cusps,  and  thus  forming  an  aperture  through  which  the 
blood  escapes  back  into  the  left  ventricle  during  diastole.  Kupture 
or  perforations  of  the  valves,  and  relative  insufficiency  from  dilation 
of  the  aortic  ring,  may  also  give  rise  to  an  upper  or  middle  sternal 

murmur  of  diastolic  in  time. 
21 


290  PHYSICAL    DIAGNOSIS 

The  mitral  presystolic  murmur,  as  its  name  implies,  occupies  the 
end  portion  of  diastole,  and  ceases  with  the  beginning  of  the  first  or 
ventricular  systolic  sound.  It  is  rarely  heard  during  the  first  third 
or  half  of  the  diastolic  period.  The  augmentation  of  intensity  which 
characterizes  it  as  it  approaches  the  first  sound  is  due  to  the  auricular 
systolic  impulse  given  to  the  obstructed  flow  of  blood  at  the  mitral 
orifice.  This  murmur  is  generally  due  to  obstruction  or  stenosis  at 
the  mitral  orifice,  especially  from  "  adhesion  of  the  anterior  and  pos- 
terior mitral  cusps  to  each  other  along  their  lateral  edges."  A  mur- 
mur which  occurs  during  the  whole  of  diastole — that  is,  while  the 
blood  should  be  noiselessly  passing  from  the  auricle  to  the  ventricle 
(mitral  diastolic  murmur] — and  before  the  auricle  contracts,  may 
rarely  be  heard  in  certain  cases  where  the  pressure  in  the  auricle 
is  high  and  the  ventricular  suction  power  vigorous. 

The  tricuspid  regurgitant  murmur,  of  all  the  right-sided  lesions 
of  the  heart,  is  the  most  common.  It  is  usually  secondary  to  advanced 
mitral  disease  in  which  the  resultant  turgid  pulmonary  circulation 
has  taxed  compensatory  hypertrophy  of  the  right  ventricle  so  long 
or  so  severely  that  weakening  and  dilation  ensue,  with  relative  in- 
sufficiency at  the  tricuspid  orifice  from  non-approximation  of  the  cusps 
during  systole.  At  the  same  time  there  may  be  coincident  endo- 
carditis, affecting  and  distorting  the  valve,  however.  This  murmur 
may  bear  the  same  relation  to  the  first  sound  and  the  succeeding 
short  silence  which  the  mitral  systolic  does.  Diastolic  and  presystolic 
tricuspid  murmurs,  and  the  systolic  and  diastolic  pulmonary  valve 
murmurs  occur  with  extreme  infrequency,  and  are  usually  of  con- 
genital origin,  although  sometimes  due  to  ulcerative  endocarditis. 
Other  lesions  of  a  congenital  nature  may  be  associated  with  pulmonary 
murmurs,  such  as  patent  ductus  arteriosus,  open  foramen  ovale,  or 
imperfect  closure  of  the  ventricular  septum.  The  systolic  murmurs 
heard  in  the  pulmonic  region  are  more  often  functional  or  anemic  in 
causation.  The  diastolic  murmur  of  pulmonary  insufficiency  may  be 
relative  from  persistent  high  pressure  in  the  pulmonary  artery  leading 
to  dilation  of  the  orifice,  a  mitral  lesion  being  the  primary  cause. 

(3)  DIRECTION  OF  TRANSMISSION. — Of  the  four  principal  organic 
valvular  murmurs  met  with,  but  one,  the  mitral  presystolic,  is  not 
transmitted  along  the  lines  of  the  blood  current  beyond  the  area  of 
its  maximum  loudness,  although  it  may  have  an  immediately  sur- 
rounding area  of  several  inches  of  conduction.  The  rule  is  that 
murmurs  of  obstruction  are  transmitted  in  the  direction  of  the  passing 
current  of  blood,  and  that  those  of  i»$»ffieiency  proceed  along  the 


AUSCULTATION  291 

lines  of  the  regurgitating  currents.  The  extent  of  diffusion  of  a 
murmur  depends  upon  the  quality  and  strength  of  the  vibrations 
producing  it,  the  condition  of  the  cardiac  tissues  near  the  diseased 
orifice,  the  proximity  or  remoteness  of  relation  of  the  cavity  of  the 
heart  in  which  the  murmur  originates  to  the  chest  wall,  and  structural 
variations  affecting  conductivity  in  the  adjacent  tissues,  as  the  ribs, 
sternum,  and  the  presence  or  absence  of  pulmonary  consolidations  or 
cavities.  The  lines  of  selective  propagation  of  the  individual  murmurs 
will  be  considered  separately. 

Mitral  Systolic  Murmur. — This  murmur,  significant  of  insuffi- 
ciency at  the  left  auriculoventricular  valve,  is  transmitted  outward — 
toward  the  left — and  slightly  upward.  Even  a  soft  murmur  may  be 
audible  as  far  as  the  anterior  axillary  line,  in  the  fifth  interspace. 
Louder  murmurs,  besides  being  heard  over  the  whole  precordium, 
sometimes  even  to  the  right  of  the  sternum,  are  usually  transmitted 
as  far  as  the  angle  of  the  left  scapula,  or  two  interspaces  above  the 
angle,  and  in  exceptional  cases  even  to  the  right  scapula.  Obviously, 
the  diffusion  of  the  mitral  systolic  murmur  extends  over  a  wider  area 
when,  as  often  occurs,  the  apex  is  displaced  downward  and  to  the  left, 


FIG.  60.  —  MITRAL  SYSTOLIC  MURMUR.  This  may  indicate  mitral  insufficiency,  anemia, 
acute  infectious  disease  (myocarditis),  left  ventricular  dilation,  malformation 
of  the  heart,  or  acute  endocarditis.  The  circle  indicates  the  point  of  maximum 
intensity,  the  arrow  the  line  of  selective  transmission.  The  radiating  lines  repre- 
sent the  area  of  audibility.  If  of  sufficient  intensity,  the  murmur  may  be  heard 
over  the  entire  chest.  (Butler.)  ft 


and  is  in  contact  with  the  chest  wall  to  a  greater  extent,  because  of 
hypertrophy  of  the  left  ventricle.  It  should  be  noted  that  this  murmur 
may  also  be  transmitted  with  distinct  intensity  to  the  left  base  of 


292 


PHYSICAL    DIAGNOSIS 


the  heart,  near  the  left  auricle,  into  which  the  regurgitating  blood 
flows,  especially  when  that  cavity  is  dilated. 

As  the  reflex  current  of  blood,  then,  passes  inward  and  backward, 
we  must  necessarily  trace  the  vibrations  of  its  course  of  transmission 
around  the  left  side  of  the  chest  posteriorly.  Transmission  of  the 
murmur  to  the  right  is  limited  by  the  deadening  effect  of  the  right 
ventricle. 

Mitral  Presystolic  Murmur. — As  intimated  before,  this  murmur 
is  seldom  transmitted  more  than  a  trifle  beyond  its  area  of  maximum 


FIG.  61. — MITRAL  PUESYSTOLIC  MURMUR.     This  may  be  caused  by  mitral  obstruction*?"1^ 
aortic  incompetence  ("Flint"  murmur),  and  slight  aortic  stenosis  and  adherent 
pericardium.     The  circle  shows  the  point  of  maximum  intensity  and  the  usual 
strict  localization  of  this  murmur.     The  radiating  lines  represent  its  possible  ex- 
tent of  audibility.     Apex  indicated  by  the  cross.     (Butler.) 

intensity,  just  within  and  above  the  apex-beat.  This  is  because  the 
direction  of  the  vibrating  blood  current  passing  through  the  obstructed 
mitral  orifice  is  precisely  toward  the  apex,  and  to  the  fact  that  the 
weakened  left  ventricle  is  remote  from  the  chest  wall  on  account  of 
the  intervening  right  ventricle,  which  is  dilated,  flaccid,  and  also 
non-conducting.  Nevertheless,  it  is  not  rare  to  find  a  presystolic 
murmur  diffused  over  a  larger  area  than  usual.  Thus,  its  area  of 
audition  may  extend  to  the  right  as  far  as,  or  even  a  little  beyond, 
midsternum;  to  the  left  as  far  as  the  anterior  axillary  line,  and 
between  the  third  and  sixth  interspaces. 

Although  the  mitral  area  presystolic  murmur  is  almost  always  due 
to  obstruction  at  this  orifice,  in  some  exceptional  cases  it  may  really 
be  caused  by  aortic  insufficiency  ("Mint  murmur").  It  is  believed 


AUSCULTATION 


293 


that  this  murmur  is  due  to  the  vibrations  of  the  mitral  cusps  as  they 
are  caught  between  the  two  currents  of  blood  flowing  into  the  dilated 
left  ventricle,  one  from  the  aorta  (the  regurgitating)  and  one  from 
the  left  auricle. 

Earely.a  presystolic  murmur  in  the  mitral  area  may  be  produced 
by  aortic  obstruction,  the  first  sound  beginning  slowly  and  roughly, 
and  by  adherent  pericardium. 

Aortic  Systolic  Murmur. — This  is  propagated  distinctly  over  the 
manubrium  sterni,  and  up  into  the  carotids.  It  may  be  heard,  also, 
over  the  subclavian  arteries.  As  this  murmur  is  often  quite  loud,  it 
may  be  heard  over  a  large  area  of  the  chest,  being  conducted,  though 
less  audibly,  by  the  sternum,  and  perhaps  by  the  heart  itself,  down- 
ward and  to  the  left  as  far  as  the  apex,  and  may  be  mistaken  there 


FIG.  62. — AORTIC  SYSTOLIC  MUKMUR.  This  may  be  due  to  aortic  stenosis,  anemia, 
dilatation  of  the  aorta,  roughening  of  the  aortic  segments  of  the  aorta,  inequalities 
of  the  valve  in  aortic  incompetence,  or  aneurism  of  the  arch  of  the  aorta.  Circles 
show  the  points  of  maximum  intensity  and  the  arrows  the  lines  of  propagation 
(into  carotids  and  subclavians)  of  the  murmur.  (Butler.) 


for  a  mitral  systolic  murmur  unless  its  area  of  greatest  loudness 
above  and  its  diffusion  into  the  great  vessels  of  the  neck  are  care- 
fully noted. 

Aortic  Diastolic  or  Regurgitant  Murmur. — This  most  constant 
murmur,  as  regards  its  lines  of  transmission,  has  an  area  of  audibil- 
ity that  extends  downward  from  the  middle  of  the  sternum,  at  the 
level  of  the  third  rib  or  interspace,  and  to  the  left,  being  heard  fre- 
quently over  the  fourth  and  fifth  interspaces  from  the  left  sternal 
border  to  the  apex.  This  conductivity  may  be  due  to  the  "intimate 


294 


PHYSICAL    DIAGNOSIS 


relation  of  the  aortic  cusps  with  the  auriculoventricular  septum  of 
the  right  side  of  the  heart."    A  diastolic  aortic  murmur  best  heard 


r 


\ 


FIG.  63. — AORTIC  DIASTOLIC  MURMUR.  This  may  be  due  to  aortic  incompetence. 
relative  aortic  incompetency,  or  anemia  (rare).  The  solid  circle  shows  the  usual 
point  of  maximum  intensity,  the  white  circles  show  the  occasional  points  of  maxi- 
mum intensity,  and  the  arrow  shows  the  direction  of  selective  transmission. 
(Butler.) 

at  the  apex  is  held  by  Foster  to  indicate  an  affection  of  the  left 
posterior  cusp  of  the  valve. 

Tricuspid  Systolic  Murmur. — This  is  the  commonest  of  the  right- 
sided  affections,  and  is  usually  secondary   (relative  insufficiency)   to 


FIG.  64. — TRICUSPID  SYSTOLIC  MURMUR.  This  is  significant  of  relative  tricuspid  in- 
competency due  to  dilatation  of  the  right  ventricle  arising  from  left-side  disease  or 
anemia.  The  circle  shows  the  point  of  maximum  intensity.  It  is  sometimes 
heard  over  the  area  indicated  by  the  radiating  lines.  (Butler.) 

extreme  tension  and  pressure  within  the  pulmonary  circulation  from 
mitral  disease,  a  previously  compensatory  hypertrophy  of  the  right 


AUSCULTATION  295 

ventricle  giving  way  to  dilation  because  of  the  backward  stress,  and 
consequently  to  incompetency  of  the  tricuspid  orifice. 

The  murmur  is  conducted  partly  by  the  regurgitating  current  and 
partly  by  the  chords  tendineae,  upward  from  the  area  of  maximum 
intensity  at  the  base  of  the  ensiform  cartilage,  and  to  the  right  as 
far  as  the  third  rib  near  its  sternal  junction,  and  to  the  left  over  the 
area  of  absolute  cardiac  dulness  toward  the  apex,  the  extent  of  diffu- 
sion depending  upon  the  degree  of  hypertrophic  dilation  of  the 
ventricles. 

Tricuspid  Presystolic  Murmur. — This  infrequent  murmur  has  an 
area  of  audition  which  corresponds  practically  with  the  superficial 
cardiac  dulness,  and  may  be  propagated  to  the  apex  of  the  right 
ventricle,  although  its  maximum  and  total  audibility  may  be  circum- 
scribed to  the  lower  end  of  the  sternum. 

Pulmonic  Systolic  Murmur. — This  murmur  is  propagated  upward 
and  slightly  to  the  left  along  the  course  of  the  pulmonary  artery, 
from  its  point  of  greatest  intensity  at  the  left  second  interspace  close 
to  the  sternum.  As  an  evidence  of  congenital  malformation  of  the 
heart,  this  murmur  is  extremely  rare;  less  so  as  the  result  of  pul- 
monary stenosis  or  narrowing  from  traction  or  torsion  of  the  artery 
due  to  shrinking  of  the  upper  lobe  of  the  lung  or  displacement  of  the 
heart.  As  a  sign  of  anemia,  occurring  as  a  hemic  or  functional 
murmur,  however,  it  is  met  with  often;  similarly,  in  connection  with 
the  excited  tachycardiac  action  in  exophthalmic  goiter.  Even  a  trans- 
mitted mitral  systolic  murmur  or  a  cardiorespiratory  murmur  may 
be  heard  in  this  region. 

Pulmonic  Diastolic  Murmur. — This  very  rare  murmur  has  an  area 
of  diffusion  downward  from  the  pulmonic  (left  second)  interspace, 
along  the  left  border  of  the  sternum  as  far  as  the  fourth  interspace. 
It  is  not  improbable  that  the  murmur  is  mistaken  sometimes  for  aortic 
regurgitation.  It  may  occur  from  congenital  malformation  of  the 
valve,  from  ulcerative  endocarditis,  or  from  relative  insufficiency  due 
to  extreme  blood  pressure  in  the  pulmonary  artery. 

(4)  QUALITY,  INTENSITY,  ETC.,  OF  MURMURS. — The  quality  of 
a  murmur  differs  characteristically  from  that  of  the  normal  heart 
sounds.  While  the  latter,  with  their  rhythmical  "lub-dup,"  convey 
the  impression  of  the  valve  tension  of  a  smoothly  acting  steam-pump, 
the  former  represent  the  peculiar  blowing,  swishing,  or  whistling 
sounds  of  the  pump  with  disordered  valve  action.  These  abnormal 
sounds  have  been  likened  to  the  utterance  of  the  various  syllables 
"  uf,"  "  uv,"  "  ush,"  "  urr,"  "  b-r-r-r,"  etc. 


296  PHYSICAL    DIAGNOSIS 

As  the  PITCH  and  QUALITY  of  a  sound  are  intimately  associated, 
we  may  refer  to  organic  endocardial  murmurs  as  low-pitched  blowing, 
like  the  sound  of  air  passing  through  a  large  tube  ("  bellows  sound"), 
or  high  pitched  and  whistling  or  scraping.  Many  low-pitched  mur- 
murs are  lightly  aspirated,  and  may  simulate  closely  an  inspiratory 
whiff  of  adjacent  normal  lung;  others  may  have  a  rumbling.,  rustling, 
or  rasping  quality.  The  former  may  be  imitated  somewhat  by  whis- 
pering the  letter  "  f,"  or  the  vowel  sounds  "  oo,"  "  u,"  "  ah,"  "  au," 
the  latter  by  guttural  or  growling  tones.  Some  of  the  higher-pitched 
murmurs  may  even  be  twanging,  or  musical  and  singing,  in  character. 

Although  none  of  the  qualities  just  mentioned  possess  any  value 
in  the  differential  diagnosis  of  the  pathologic  nature  of  the  disease 
affecting  the  valve  or  the  structures  around  its  orifice,  they  may  have 
distinct  signification  of  the  physical  nature  of  the  lesion;  that  is, 
soft,  blowing  murmurs  are  usually  suggestive  of  regurgitation,  while 
obstructive  murmurs  are  generally  rough  and  grating.  Murmurs  are 
not  only  variable  in  quality,  but  a  single  murmur  may  change  in 
character  because  of  changes  in  the  size  and  structure  of  the  orifices 
and  chambers  of  the  heart,  in  the  force  of  cardiac  action,  and  because 
of  anemic  alterations  of  blood  composition. 

The  qualities  of  the  most  common  murmurs  met  with  usually  are 
as  follows:  The  mitral  regurgitant  or  systolic  murmur  has  a  soft, 
blowing  quality.  The  aortic  obstructive  or  systolic  murmur  is  harsh, 
sawing,  or  filing  in  character,  according  to  the  extent  and  degree  of 
narrowing  and  calcareous  deposit  upon  the  valve.  The  aortic  regur- 
gitant or  diastolic  murmur  is  generally  very  soft  and  blowing,  often 
less  harsh  than  the  mitral  regurgitant  murmur,  and  sometimes  hardly 
audible  to  the  ear  of  the  most  careful  examiner.  Exceptional  cases 
occur,  however,  where  this  murmur  may  be  quite  rough  and  vibrant, 
even  musical.  The  quality  of  the  mitral  stenotic  or  presystolic  mur- 
mur is  distinctive  because  of  the  peculiar  blubbering,  churning  sound, 
rougher  than  a  regurgitant  murmur,  but  softer  than  the  sawing  quality 
of  the  aortic  stenotic  murmur.  It  may  be  simulated  by  vocalizing 
the  syllable  "  rrrb,"  the  last  letter  terminating  abruptly  with  the  im- 
mediately following  first  sound  of  the  heart;  so  close,  indeed,  that 
not  infrequently  the  murmur  seems  to  coincide  with  this  sound,  and 
thus  having  a  systolic  time. 

The  INTENSITY  of  murmurs  is  as  variable  as  their  quality.  It 
does  not  depend  necessarily  upon  the  severity  of  the  valvular  lesions, 
but  may  be  suggestive  often  of  the  character  of  the  lesions,  whether 
causing  obstruction  or  insufficiency.  Obstructive  murmurs  are,  as  a 


AUSCULTATION"  297 

rule,  louder  than  the  regurgitant  ones.  The  loudness  of  murmurs 
is  more  often  affected  by  the  force  of  the  heart's  action,  temporarily, 
as  from  excitement  or  treatment;  thus  emotion,  exercise,  and  such 
drugs  as  digitalis,  strophanthus,  and  strychnine  may  exaggerate  their 
intensity.  Therefore,  not  only  do  murmurs  vary  in  intensity  in  dif- 
ferent individual  cases,  or  in  multiple  lesions  in  the  same  individual, 
but  they  may  fluctuate  in  connection  with  a  single  lesion  in  auscul- 
tating the  individual  at  different  times. 

(a)  The  force  of  the  blood  stream,  and  consequently  the  strength 
of  the  ventricular  muscle,  is  the  most  important  diagnostic  and  prog- 
nostic factor  which  is  indicated  by  the  intensity  of  a  murmur.  Natu- 
rally, the  systolic  murmurs  are  usually  louder  than  the  diastolic, 
other  things  being  equal,  because  stronger  blood  eddies  are  set  up 
by  ventricular  contraction  than  by  vascular  recoil  and  ventricular 
dilation.  Furthermore,  a  loud  systolic  murmur  implies  hypertrophy 
and  good  compensation — a  favorable  sign;  and  conversely,  if  while 
the  case  is  under  observation  such  a  loud  murmur  becomes  gradually 
weaker,  or  if  the  murmur  disappears,  even,  it  means  that  compensation 
is  failing  from  degeneration  and  dilation  of  the  cardiac  muscle.  Un- 
der treatment,  a  previously  weakened  or  inaudible  murmur  may  again 
assume  distinct  loudness;  so  that  the  mere  presence  or  intensification 
of  a  murmur  may  be  a  hopeful  indication  of  the  condition  of  a 
patient's  myocardium.  Gibson  states  that  the  mitral  presystolic 
murmur  is  particularly  prone  to  disappear  and  reappear,  not  only 
because  of  the  variable  energy  of  the  left  auricle,  but  especially  be- 
cause with  weakening  and  distention  of  the  right  ventricle  the  apex 
is  pushed  away  from  the  chest  wall,  and  thus  prevents  the  conduction 
of  the  sound. 

(&)  The  degree  as  well  as  the  nature  of  the  lesion  affects  the 
loudness  of  a  murmur.  As  a  rule,  the  narrower  the  obstructed  orifice 
as  compared  with  the  size  of  the  cavity  beyond  the  louder  the  murmur. 
Marked  aortic  stenosis  is  usually  very  loud  also,  because  of  the  added 
feature  of  a  vigorous  hypertrophy  to  enable  the  left  ventricle  to  over- 
come the  difficulty  in  the  attempt  to  maintain  a  balance  of  the  circu- 
lation. Occasionally,  however,  loud  murmurs  are  heard  during  life 
which  the  slight  changes  found  subsequently  post  mortem  seem  hardly 
related  to.  On  the  other  hand,  hard,  calcareous  excrescences  upon 
the  valve  leaflets,  as  in  the  aortic  disease  of  very  old  people,  are  often 
accompanied  with  loud,  rough  murmurs;  these  may  even  be  musical 
in  some  cases,  when  perforations  of  valve  leaflets  may  be  suspected, 
or  floating  shreds  of  torn  leaflets  or  papillary  muscles. 


298  PHYSICAL   DIAGNOSIS 

(c)  Posture,  exercise,  and  respiration  influence  the  intensity  of 
murmurs.     Of  the  two  principal  varieties  of  lesion,  the  obstructive 
murmurs  are  louder  when  the  patient  sits  or  stands,  especially  when 
the  auriculoventricular  orifices  are  affected.     Regurgitant  murmurs, 
on  the  contrary,  are  most  distinct  when  the  patient  is  recumbent. 
This  is  often  true  of  the  aortic  diastolic  murmur,  although  it  must 
be  admitted  that,  as  regards  posture,  the  aortic  and  pulmonary  valve 
murmurs  are  less  affected  than  are  the  mitral  and  tricuspid.     Both 
mitral  obstruction  and  insufficiency  may  be  better  elicited  by  their 
murmurs  while  the  patient  lies  flat  upon  the  back.    Nevertheless,  the 
rolling,  "  flowing "  sound  of  a  presystolic  murmur,  which  is  quite 
easily  heard  when  the  patient  is  sitting  up,  may  in  some  cases  dis- 
appear nearly  or  entirely  when  he  lies  down. 

The  effects  of  exercise  have  diagnostic  value  not  only  concerning 
the  audibility  of  the  murmur,  but  also  the  condition  of  the  heart 
muscle.  A  murmur  so  feebly  heard  ordinarily  that  only  after  a  brisk 
walk  of  forty  or  fifty  paces,  stooping  and  straightening  of  the  body, 
and  the  like,  is  it  rendered  most  distinctly  audible,  indicates  a  lesion 
of  comparative  mildness,  or  a  myocardium  of  developing  weakness. 
On  the  other  hand,  marked  rapidity  of  cardiac  action  following  forced 
exertion  may  make  it  difficult  to  time  or  even  detect  a  murmur  which 
at  a  previous  examination,  with  the  patient  at  rest,  was  patently 
evident. 

The  respiratory  period  affects  the  intensity  of  a  murmur.  During 
inspiration,  while  the  lung  is  distended  as  it  overlaps  the  heart,  dimin- 
ished loudness  of  a  murmur  is  usually  noted,  especially  when  the 
mitral  valve  is  affected.  Hence,  organic  murmurs  are  better  heard 
at  the  end  of  expiration,  as  contrasted  with  the  functional  and 
cardio-respiratory  murmurs,  which  are  more  audible  at  the  end  of 
inspiration. 

(d)  The  specific  gravity  and  plasticity  of  the  Hood  influences  the 
loudness  of  a  murmur.     In  cases  of  anemia  with  reduction  in  the 
number  of  the  corpuscles,  and  in  the  fibrin  and  other  proteid  per- 
centages  (hydremia),  murmurs  are  louder  than  where  these  factors 
are  more  nearly  normal.     And  thus  we  find  that  following  a  case 
of  severe  acute  articular  rheumatism  with  blood  damage,  a  mitral 
insufficiency  murmur  will  be  louder  than  later,  when  treatment  has 
corrected  the  anemia. 

The  DURATION  of  murmurs  differs  decidedly  in  many  instances; 
in  some  it  is  short,  in  others  so  long  as  to  occupy  most  of  systole  or 
diastole.  Practically  murmurs  always  have  longer  duration  than 


AUSCULTATION  299 

either  of  the  heart  sounds.  Murmurs  of  obstruction  are  commonly 
of  longer  duration  than  those  of  regurgitation,  as  it  takes  longer  for 
the  blood  current  to  pass  through  a  narrowed  than  through  a  leaking 
orifice.  If  the  disturbance  is  sufficiently  great,  however,  and  the 
heart's  action  sufficiently  energetic,  an  aortic  regurgitant  murmur 
may  exist  throughout  diastole,  as  well  as  a  mitral  stenotic.  The 
mitral  systolic  murmur  is  usually  short  in  duration,  being  but  a 
prolongation  of  the  first  sound  (with  roughening),  or  occupying 
a  portion  of  the  silence  between  the  first  and  second  sounds.  Murmurs 
which  replace  either  of  the  heart  sounds  are  generally  of  longer  dura- 
tion than  those  which  occur  separately  in  the  short  or  long  silences, 
and  are  of  correspondingly  graver  significance. 

(C)   MULTIPLE  OR  COMBINED  MURMURS 

These  result  from  a  combination  of  (usually)  two  valvular  de- 
fects, very  infrequently  three,  and  with  extreme  rarity  four  defects. 
One  should  naturally  seek  to  know  whether  a  single  or  several  valvu- 
lar lesions  coexist  whenever  a  murmur  is  heard  over  more  than  one 
valve  area.  As  the  intensity  of  many  murmurs  permits  of  their 
propagation  some  distance  beyond  their  areas  of  maximum  audition, 
and,  as  shown  before,  their  transmissibility  with  the  direct  and  re- 
gurgitating blood  currents  being  important  phenomena,  this  question 
as  to  multiple  murmurs  must  arise  almost  constantly,  whether  they 
be  present  or  not.  Indeed,  to  quote  the  words  of  DaCosta  more  than 
a  generation  ago :  "  How  important  is  it,  then,  to  examine  each  por- 
tion of  the  heart  separately,  as  much  for  the  purpose  of  saying  what 
is  not  as  what  is  deranged." 

This  problem  of  diagnosis  arises,  of  course,  only  when  the  murmur 
heard  is  everywhere  the  same  in  rhythm — that  is,  systolic  or  diastolic 
in  the  various  regions;  thus,  a  systolic  murmur  heard  over  the  pre- 
cordium  may  mean  a  combination  of  aortic  obstruction  and  mitral 
insufficiency.  Obviously,  when  both  a  systolic  and  diastolic  murmur 
are  heard,  even  at  one  valve  area,  or  anywhere  over  the  chest,  two 
lesions  must  be  evident  either  at  one  orifice,  as  aortic  stenosis 
and  regurgitation,  or  at  two  orifices,  as  aortic  and  mitral  regur- 
gitation. 

Where  a  widely  audible  murmur  is  heard,  therefore,  the  difficulty 
of  interpretation  may  be  twofold.  First,  it  may  be  supposed  that 
but  one  valve  is  diseased  instead  of  two;  that  the  murmur  heard  in 
the  second  area  is  merely  transmitted  from  the  first.  Secondly,  on  the 


300  PHYSICAL    DIAGNOSIS 

other  hand,  it  may  be  inferred  that  there  is  a  combination  of  two 
valvular  lesions  when  there  is  really  only  one,  as  when  a  diastolic 
murmur  heard  at  the  apex  is  attributed  to  a  mitral  stenosis  as  well 
as  an  aortic  insufficiency. 

To  differentiate  these  signs,  the  appended  points  in  observation 
may  be  applied  successfully.  They  are  based  upon  two  facts  already 
described,  namely,  that  the  various  valvular  lesions  commonly  met 
with  have  selective  areas  of  maximum  intensity,  and  more  or  less 
characteristic  differences  of  quality. 

(1)  For  example,  auscultating  at  the  base  of  the  heart,  near  the 
third  left  sternocostal  junction,  we  hear  a  feeble  systolic  murmur. 
Choosing  the  two  valve  points,  mitral  and  aortic,  for  first  considera- 
tion, we  trace  the  murmur  from  aOrta  to  apex,  step  by  step,  noting 
changes  of  intensity  and  quality  in  approaching  and  receding  them. 
Here  we  note  that  in  approaching  the  aortic  region,  over  the  manu- 
brium  and  to  the  second  right  intercostal  space,  the  murmur  becomes 
louder,  harsher,  and  more  widely  propagated,  especially  upward  into 
the  carotid  arteries.  There  is  no  doubt  that  this  is  an  aortic  ob- 
structive murmur.  Eetracing  with  the  stethoscope,  the  murmur  be- 
comes fainter  and  softer,  though  distinctly  audible,  in  the  third  and 
fourth  left  interspaces;  in  fact,  it  seems  to  be  a  trifle  more  distinct 
over  the  right  ventricle,  at  its  left  border  (fourth  interspace  outside 
the  paras ternal  line).  In  the  fifth  interspace,  over  the  apex,  which 
is  a  little  outside  the  midclavicular  (nipple)  line,  the  systolic  murmur 
is  still  louder,  yet  not  so  peculiarly  harsh  as  above,  and  is  shorter  in 
duration.  It  is  also  heard,  tapering  off  in  distinctness,  for  several 
inches  toward  the  left  axilla.  We  conclude  from  the  last  observation 
that  there  is  another,  a  mitral  systolic  (regurgitant)  murmur,  because 
of  the  two  areas  of  maximum  intensity  corresponding  to  valve  points, 
with  an  intervening  space  of  least  intensity  for  the  murmurs  best 
heard  at  both,  and  because  the  character  or  quality  of  both  these 
systolic  murmurs  is  different,  with  lines  of  propagation  in  har- 
mony with  what  we  know  of  either  of  the  murmurs  considered 
singly. 

As  Gibson  points  out,  another  serviceable  aid  may  be  found  in 
the  fact  that  "  if  the  murmur  is  louder  at  the  apex  than  it  is  over  the 
left  edge  of  the  heart  in  the  space  above  the  apex,  or  the  rib  above 
that,  the  probability  is  that  there  is  a  mitral  as  well  as  the  aortic 
murmur.  The  reason  of  this  last  is  apparent,  for  if  the  murmur  at 
the  apex  is  the  aortic  systolic  propagated  downward  by  the  left  ven- 
tricle, there  is  no  reason  why  it  ought  not  to  be  as  audible  at  any 


AUSCULTATION"  301 

point  along  the  left  edge  of  the  heart  as  at  the  apex."  In  cases, 
however,  where  the  aortic  murmur  is  extremely  loud  and  distinctly 
conducted  over  the  whole  precordium,  the  presence  of  a  mitral  systolic 
murmur  may  be  inferred  by  the  help  of  the  discovered  evidence  of 
elevated  tension  and  pressure  in  the  pulmonary  artery,  manifested 
by  an  accentuation  and  heightened  pitch  of  the  pulmonic  second 
sound. 

(2)  Again,  a  soft  diastolic  murmur  is  heard  at  the  base,  at  the 
topographic-anatomic  valve  area,  also  in  the  right  second  interspace, 
with  equal  but  not  greater  intensity.     Approaching  the  apex,  down- 
ward and  to  the  left,  the  murmur  becomes  rougher  and  longer  in 
duration,  with  a  maximum  of  intensity  just  inside  the  apex.    Is  this 
a  case  of  transmitted  aortic  regurgitant  murmur  or  one  of  mitral 
stenosis,  or  both?    Here  the  same  method  of  tracing  from  one  valre 
point  to  the  other,  and  noting  changes  in  attributes,  may  be  pursued, 
remembering  that  the  mitral  presystolic  murmur  is  not  transmitted 
upward,  etc.     For  further  diagnostic  data,  the  signs  obtained  by  the 
other    methods    of   examination   must   be    correlated,    especially    in 
connection  with   the   size   of   the   heart   chambers,   position    of   the 
apex-beat,  and  the  like,  as  will  be  pointed  out  later  in  describing 
some  of  the  consequences  of  the  various  lesions  upon  the  cardiac 
walls. 

(3)  Auscultating  near  the  base  of  the  heart,  in  a  third  instance, 
a  systolic  murmur  is  heard  with  slight  intensity.     Advancing  to  the 
aortic  and  pulmonic  areas  with  the  stethoscope,  the  murmur  is  in- 
audible.   Passing  downward  over  the  body  of  the  heart,  in  the  para- 
sternal  line,  the  murmur  is  heard  a  little  better  than  in  the  third 
left  interspace  near  the  sternum,  but  still  rather  feebly.     It  becomes 
distinctly  stronger,  however,  as  the  apex  is  approached  in  the  fifth 
interspace,  and  is  quite  well  audible  for  one  inch  outside  the  nipple 
line.     Toward  the  right,  in  following  along  the  fifth  interspace,  we 
notice  that   the  systolic  murmur,   slightly  changed  in   quality   and 
pitch,  also  becomes  louder  until  the  tricuspid  area  is  reached,  where 
its  maximum  is  heard.     That  we  are  dealing  with  a  double  valvular 
abnormality  is  evident — tricuspid  and  mitral  insufficiency. 

The  combinations  of  valvular  lesions,  as  manifested  by  their  ac- 
companying murmurs,  are  principally  the  following: 

(a)  Aortic  regurgitation  and  stenosis;  mitral  regurgitation.  We 
hear  the  double,  to-and-f ro  or  "  seesaw  "  murmur  at  the  aortic  area, 
and  a  soft  systolic  murmur  at  the  apex.  The  aortic  second  sound  is 
usually  obliterated  by  the  systolic-diastolic  rushing  sounds. 


302 


PHYSICAL    DIAGNOSIS 


(6)  Aortic  regurgitation  and  mitral  regurgitation.     A  soft  dias- 
tolic  murmur  transmitted  from  the  base  to  the  apex  of  the  heart, 


FIG.  65. — COMBINED  MURMURS  OF  AORTIC  INCOMPETENCE  AND  STENOSIS  AND  MITRAL 
INCOMPETENCY.     (Butler.) 

followed   by   a   short   or    systolic   murmur    transmitted   to    the   left 
axilla. 

(c)  Mitral  stenosis  and  regurgitation.     A  presystolic,  churning 
murmur,  ending  abruptly  with  the  first  sound,  and  followed  by  the 
systolic  murmur. 

(d)  Aortic  stenosis  and  mitral  stenosis.     A  rough  systolic  mur- 
mur, heard  over  the  upper  portions  of  the  chest,  with  its  maximum 
intensity  at  the  right  second   interspace,   and   propagated   into  the 
carotids;    then   the   second   sound;    then   the    rolling   murmur   just 
before  the  next  first  sound,  its  audition  circumscribed  around  the 
apex. 

(e)  Mitral  regurgitation  and  tricuspid  regurgitation. 
(/)   Mitral  stenosis  and  aortic  regurgitation. 

(g)   Aortic  regurgitation;  mitral  stenosis  and  regurgitation. 
(h)  Aortic   stenosis;   mitral  regurgitation;   trieuspid   regurgita- 
tion. 


AUSCULTATION 


303 


Tabulated  Summary  of  the  Four  Principal  Organic 
Endocardial  Murmurs 


LESION. 

AREA  OP  MAXIMUM 
INTENSITY. 

RHYTHM. 

AREA  OP  AUDITION  AND  DIRECTION 
OF  TRANSMISSION. 

Aortic  obstruc- 
tion or  steno- 
sis. 

Second  right 
interspace. 

Systolic. 

Over  the  upper  sternal  region  ; 
sometimes  over  the  whole  pre- 
cordium  ;  transmitted  into 
carotid  artery. 

Aortic  insuffi- 
ciency. 

Same,  or  left 
border  of  ster- 
num at  level 
of  third  rib. 

Diastolic. 

Over  lower  two-thirds  of  ster- 
num, and  precordium  to  left 
of  sternum;  transmitted  to 
apex. 

Mitral  stenosis. 

Apex  of  left 
ventricle. 

Presystolic. 

Circumscribed  to  apical  region; 
rarely  transmitted. 

Mitral  insuffi- 
ciency. 

Same. 

Systolic. 

Over  apical  and  nipple  areas  ; 
usually  transmitted  toward 
axilla;  round  to  angle  of 
scapula  ;  sometimes  upward 
and  inward  to  left  auricular 
region. 

(D)    FUNCTIONAL  OR  ACCIDENTAL  MURMURS 

These  are  adventitious  sounds  occurring  in  certain  diseased  states, 
more  or  less  general,  in  which  the  cardiac  function  is  disturbed  or 


FIG.  66. — SHOWING  THE  RELATIVE  FREQUENCY  OF  ANEMIC  MURMURS  AT  THE  VARIOUS 
ORIFICES  OF  THE  HEART.     Percentages  from  Sansom.     (Butler.) 

the  circulating  blood  altered,  but  in  which  there  is  no  valvular  or 
orificial  anatomic  lesion.  They  are  thus  found  in  association  with 
cardiac  neuroses,  and  with  anemic  and  some  febrile  conditions.  The 


304  PHYSICAL    DIAGNOSIS 

terms  inorganic  and  functional  are  commonly  used  to  designate  these 
murmurs  because  of  the  absence  of  any  structural  changes  affecting 
the  heart.  When  due  to  blood  states,  they  are  spoken  of  as  hemic 
or  anemic  murmurs.  As  dynamic  murmurs  they  refer  more  especially 
to  perversions  of  the  regularity,  steadiness,  poise,  or  freedom  of  the 
muscular  action  of  the  heart,  probably  with  some  disturbance  in  the 
neural  function  at  the  same  time;  these  correspond  with  the  cardio- 
muscular  murmurs  of  Drummond.  Perhaps,  as  Babcock  suggests,  the 
term  accidental  is  as  embracing  and  appropriate  as  any,  as  it  "  implies 
that  the  murmur  is  a  chance  result  of  cardiac  action." 

Characteristics  of  Accidental  Murmurs. —  (1)  As  to  location,  they 
are  usually  best  heard  at  the  base  of  the  heart,  especially  in  the  pul- 
monary valve  area,  although  they  are  not  infrequently  audible  in  the 
mitral  area,  but  seldom  in  the  aortic  or  tricuspid  areas. 

(2)  In  time,  they  are  practically  always  systolic. 

(3)  In  quality,  they  are  soft  and  blowing,  or  bellows-like. 

(4)  In  intensity,  they  are  gentle,  often  feeble;  mere  soft  aspira- 
tions, and  never  harsh,  rasping,  or  sawing. 

(5)  Their  pitch  is  often  high,  but  may  be  low,  and  their  duration 
short. 

(6)  Their  area  of  audition  is  circumscribed,  and  they  are  not 
transmitted  beyond  the  cardiac  area. 

(7)  In  some  cases,  as  in  chlorotic  or  anemic  subjects,  they  are 
accompanied  with  murmurs  in  the  veins  of  the  neck. 

(8)  They  are  usually  louder  at  the  end  of  expiration. 

(9)  They  are  not  permanent  in  character,  their  fugaciousness 
depending  upon  the  etiology,  and  varying  from  a  few  hours,  as  the 
result  of  hard  exercise,  to  days,  weeks,  or  even  months,  disappearing 
whenever  general  and  local  improvement  ensues. 

(10)  They  are  not  attended  with  evidence  of  cardiac  enlarge- 
ment. 

Functional  murmurs  may  be  produced  by  a  simple  increase  in 
the  force  and  rapidity  of  the  blood  current  in  excitable  individuals 
laboring  under  temporary  physical,  mental,  or  emotional  stress,  but  in 
whom  there  is  no  abnormality  of  size  or  structure  of  the  valve  orifices 
or  of  the  valves,  nor  of  the  specific  gravity  or  composition  of  the 
blood;  these  are  the  "true  dynamic  murmurs  of  health,  in  contradis- 
tinction to  those  due  to  some  irritability  or  irregularity  of  the  neuro- 
muscular  function  of  the  heart,  which  may,  indeed,  in  certain  cases5 
really  be  caused  by  sonic" obscure  or  latent  organic  affection  of  the 
myocardium,  as  of  patches  of  fatty  or  fibroid  degeneration. 


AUSCULTATION'  305 

Production. — The  theories  to  account  for  the  direct  origin  of  the 
accidental  murmurs  are  so  numerous,  varied,  even  antagonistic,  and 
generally  unsatisfactory,  that  one  may  be  justified  in  taking  a  more 
or  less  personal  view  based  upon  the  studies  and  experiences  of  others, 
as  well  as  one's  own  observations  and  deductions.  Hence  it  is  prob- 
able, in  the  first  place,  that  the  functional  murmurs  heard  tempora- 
rily in  those  diseases  of  a  pyrexial  or  wasting  nature  in  which  myo- 
cardial  relaxation  or  debility  is  associated,  are  really  the  result  of  a 
relative  insufficiency  of  the  auriculoventricular  openings,  or  of  some 
dilation  of  the  conus  arteriosus  of  one  or  the  other  side.  In  involve- 
ment of  the  tricuspid  or  mitral  orifice,  the  condition  is  not  always 
or  necessarily  a  dilation  of  the  opening  itself,  but  may  be  due  to 
disorder  of  the  function  of  the  papillary  muscles  and  chordae  tendinea?. 
In  these  cases  there  is  often  a  weak,  impure  first  sound  at  the  mitral 
area,  with  a  short,  soft,  systolic  murmur,  best  heard  at  the  third  or 
fourth  interspace  close  to  the  sternum  at  its  left  border,  loudest  at 
the  end  of  expiration,  and  in  the  upright  posture. 

The  fact  that  many  of  these  accidental  murmurs  are  most  distinctly 
audible  in  the  pulmonic-valve  area  may  be  explained  by  their  propa- 
gation from  their  mitral  seat  of  production  to  the  chest  wall  by 
conduction  along  the  tip  of  the  left  auricular  appendix.  In  the 
case  of  temporar}r  dilation  of  the  right  ventricle,  the  sound  of  rela- 
tive insufficiency  and  of  an  overworking  muscle  is  propagated  to  the 
pulmonic  area  as  a  tremor  (Sansom).  It  may  be  also,  as  Quincke 
pointed  out,  that  a  murmur  in  the  pulmonic  area  may  be  produced 
by  a  slight  squeezing  of  the  pulmonary  artery  against  the  chest  wall 
by  the  dilated  ventricle. 

In  the  anemic  states — chlorosis,  pernicious  anemia,  and  the  like — 
causing  the  hemic  murmurs,  the  condition  underlying  their  produc- 
tion is  essentially  the  same — that  is,  weakening  of  the  myocardial  walls 
owing  to  the  deficient  quality  and  quantity  of  blood,  imperfect  metab- 
olism— a  relative  insufficiency  resulting.  The  murmurs  of  anemia 
are  heard  usually  at  the  second  or  third  left  interspace,  near  the 
sternal  border,  although  they  may  rarely  be  audible  at  any  of  the 
other  valve  areas — -at  the  aortic  most  frequently,  then  at  the  mitral 
and  tricuspid. 

The  precise  explanation  of  the  so-called  hemic  murmurs  is  diffi- 
cult, and  at  this  time  entirely  wanting.  Sahli  and  Vierordt  agree 
in  suggesting  that  they  may  really  be  venous  murmurs  transmitted 
to  the  heart  from  the  large  veins  in  the  thorax  which  lie  behind  it. 
According  to  Cabot,  the  diastolic  functional  murmurs,  exceedingly 
22 


306  PHYSICAL    DIAGNOSIS 

rare  as  they  undoubtedly  are,  may  be  "  due  to  sounds  produced  in 
the  veins  of  the  neck  and  transmitted  to  the  innominate  or  vena  cava." 

Certain  non-valvular  or  functional  murmurs  may  also  be  caused 
by  congenital  anomalies  of  the  heart,  and  by  pressure  from  deformity 
outside  the  heart. 

While  most  of  the  accidental  murmurs  are  basic  in  location,  notably 
the  hemic  ones,  nevertheless  not  a  few  are  apical,  especially  those 
which  may  be  termed  more  properly  dynamic.  Of  the  firs!  <-l;i>~, 
chlorosis  is  a  type  of  disease;  of  the  second,  chorea.  The  chlorotic 
murmur  is  often  heard  in  the  aortic,  and  sometimes  in  the  upper 
mitral  areasrbut  in  the  former  region  is  not  usually  propagated  into 
the  arteries,  except  in  the  most  advanced  cases.  However,  as  Balfour 
points  out,  the  functional  murmurs  of  both  kinds  essentially  depend 
upon  simple  dilation  of  the  heart  from  the  debility,  weakness,  and 
relaxation  of  the  myocardium,  the  result  of  the  perversions  of  metab- 
olism and  neuromuscular  rhythm  and  power. 

Differentiation. — It  is  often  difficult  to  determine  whether  we  are 
dealing  with  a  functional  or  a  true  organic  murmur;  and,  although 
the  distinctive  points  of  the  former  have  just  been  given,  it  may  be 
well  to  put  over  against  these  a  comparative  summary  of  those  of 
the  organic  murmurs. 

Functional  murmurs  are  almost  always  systolic  in  time;  organic 
murmurs  are  frequently  diastolic. 

Functional  murmurs  usually  have  their  areas  of  maximum  in- 
tensity at  the  base,  and  in  the  pulmonic  area;  organic  murmurs,  on 
the  other  hand,  occur  more  frequently  at  the  apex,  and  when  found 
at  the  base  are  practically  limited  to  the  aortic  region. 

Functional  murmurs  are  generally  very  soft,  not  harsh  or  musi- 
cal; nor  are  they,  as  is  commonly  true  of  organic  murmurs,  trans- 
mitted beyond  the  precordium,  or  along  the  lines,  especially,  of  regur- 
gitating blood-currents. 

Functional  murmurs  are  usually  loudest  at  the  end  of  inspiration ; 
the  organic,  at  the  end  of  expiration. 

A  functional  murmur  should  always  be  suspected,  other  things 
being  equal,  whenever  the  sounds  are  heard  in  cases  of  distinct  chloro- 
sis or  other  forms  of  pronounced  anemia,  and  in  neurotic  states;  an 
organic  murmur,  whenever,  there  are  positive  evidences  of  cardiac 
enlargement,  such  as  displaced  apex-beat,  with  exaggerated  force  and 
extent  of  impulse,  etc. 

Finally,  the  functional  murmurs  differ  from  the  organic  in  being 
susceptible  to  obscuration  by  pressure  with  the  stethoscope,  and  to 


AUSCULTATION  307 

disappearance  when  the  patient  assumes  the  dorsal  or  right  lateral 
decubitus. 

Musical  murmurs,  as  intimated  before,  may  accompany  organic 
valvular,  especially  aortic,  lesions,  as  whistling,  filing,  singing,  etc., 
qualities  of  sound.  In  some  cases  they  may  be  caused  by  sclerotic 
and  calcified  aortic  cusps,  or  to  fenestrations,  or  to  tears  with  freely 
floating  ends.  Again,  the  post-mortem  findings  of  musical  murmurs 
have  been  hard  atheromatous  plaques  in  the  aorta  near  the  aortic 
orifice ;  fibrous  bands  stretched  across  the  ventricles  near  the  tricuspid 
or  mitral  orifices,  or,  as  in  a  case  reported  by  Potain,  a  cord  between 
the  ventricular  wall  and  the  edge  of  the  mitral  valve,  just  below  the 
aortic  orifice,  and  ruptured  tendinous  cords  swinging  loosely  or  form- 
ing abnormal  attachments. 

In  the  case  of  the  itinerant  young  Eussian,  to  whom  Babcock 
refers  in  his  book  on  "  Diseases  of  the  Heart  and  Arterial  System," 
p.  30,  and  whom  I  showed  to  my  class  in  the  Medico-Chirurgical 
College,  the  scar  of  a  stab  wound  over  the  right  ventricle  suggests 
that  the  singing,  systolic  murmur  of  his  "  musical  heart "  is  probably 
due  to  tricuspid  regurgitation. 

Accidental  musical  murmurs,  however,  may  also  occur  in  certain 
rare  instances.  Thus,  they  have  been  discovered  occasionally  in  neu- 
rotic, slightly  anemic  young  females  with  tachycardia,  and  who  while 
under  examination  have  exhibited  intense  nervousness,  and  visible 
and  palpable  violence  of  cardiac  action.  They  may  be  explained  as 
due  to  the  vibration  of  one  of  the  so-called  moderator  bands  or  aber- 
rant cords  sometimes  found  stretched  along  or  across  the  intraven- 
tricular  wall,  while  under  the  increased  tension  of  overfilled  chamber 
and  extremely  rapid  action. 

Cardiopulmonary  or  Cardiorespiratory  Sounds. — Although  strictly 
within  the  category  of  the  exocardial  sounds  (see  next  topic),  so 
far  as  their  origin  is  concerned,  their  presence  within  and  their  fre- 
quent proximity  to  the  precordium,  as  well  as  their  mode  of  produc- 
tion, ally  them  quite  closely  to  the  more  purely  functional  or  accidental 
murmurs ;  in  fact,  Potain  and  others  consider  all  accidental  murmurs 
practically  as  cardiopulmonary  in  origin.  By  this  compound  term  it 
is  meant  that  the  sound  is  caused  by  the  rhythmic  impact  of  the 
heart  against  the  overlapping  lung,  especially  that  portion  known  as 
the  lingula. 

The  cardiorespiratory  murmur,  which  is  not  at  all  uncommon, 
is  heard  as  a  short,  moderately  high-pitched,  whiffing  sound,  quite 
suggestive  of  the  brusk  displacement  of  air  from  the  vesicles  and 


308  PHYSICAL    DIAGNOSIS 

bronchioles  of  the  surrounding  lung.  Because  intimate  contact  be- 
tween the  heart  and  lung  is  essential  to  produce  this  sound,  it  is  natu- 
ral to  reason  that  it  will  be  most  audible  at  the  end  of  inspiration, 
fading  rapidly  with  expiration;  and  so  the  clinical  facts  are  found 
to  be.  Again,  the  cardiopulmonary  sound  ceases  to  be  heard  when 
the  breath  is  held.  With  deep  and  forcible,  though  slow  breathing, 
it  may  be  heard  throughout  the  respiratory  act,  but  always  louder 
during  inspiration.  At  other  times,  during  moderate  breathing,  one 
hears  three  or  four  distinct  and  rapidly  diminishing  pud's;  then  an 
expiratory  silence.  It  is  systolic  in  time,  as  a  rule.  Lying  upon 
the  back  or  the  right  side  usually  diminishes  the  intensity  of  this 
sound. 

The  area  of  audibility  is  limited  to  the  apical  and  left-upper 
border  regions.  The  sound  is  not  transmissible  as  are  the  valvular 
murmurs,  although  in  rare  instances  it  has  been  heard  under  the  left 
clavicle  and  scapula.  It  may  be  modified  by  external  pressure,  as  with 
a  stethoscope,  in  the  vicinity  of  its  production;  either  quality  or  in- 
tensity, or  both,  may  be  altered.  Although  the  cardiopulmonary 
sounds  may  occur  under  entirely  normal  conditions,  it  is  not  un- 
likely that  in  some  cases  there  is  a  localized  or  compensatory  emphy- 
sema against  which  the  heart  impinges  in  its  movements.  Finally, 
it  should  be  borne  in  mind  that  these  sounds  are  extremely  variable, 
and  may  be  heard  during  any  physical  relation  of  heart  to  overlying 
lung  sufficient  to  generate  them,  without  regard  to  respiration  or 
posture,  although  those  points  mentioned  above  are,  in  the  majority 
of  instances,  characteristic. 

EXOCARDIAL   SOUNDS 

The  adventitious  sounds  produced  outside  and  yet  associated  with 
the  heart,  although  not  usually  heard  beyond  the  precordial  borders, 
are  mainly  those  originating  within  the  p'ericardial  sac.  Others,  of 
less  frequent  occurrence,  may  be  pleuropericardial,  vascular,  pleural, 
pulmonary,  and  subphrenic.  Excepting  the  vascular  murmurs,  they 
are  all  characterized  by  marked  variety  of  quality,  indefiniteness  of 
relation  to  the  cardiac  cycle,  and  variability  of  signs  generally. 

Pericardial  Murmurs  or  Friction  Sounds. — As  these  names  clearly 
indicate,  they  represent  the  effects  of  the  rubbing  or  friction  of  in- 
flamed, roughened  pericardial  surfaces,  analogous  to  pleuritis,  since 
normally  these  serous  membranes,  visceral  and  parietal,  glide  over 
each  other  smoothly  and  noiselessly. 


AUSCULTATION" 


309 


Attention  will  be  directed  at  the  outset  to  the  peculiar  QUALITY 
of  the  pericardial  friction  sounds.  They  are  variously  described  as 
grazing,  grating,  scratching,  often  brushing,  shuffling,  scraping,  creak- 
ing like  leather,  rustling  or  crumpling  like  silk  or  parchment,  crunch- 
ing like  snow — all  depending  more  or  less  upon  the  dryness  of  the 
surfaces,  or  the  viscosity,  thickness,  and  chronicity  of  the  exudate. 

As  to  LOCATION,  pericardial  friction  is  best  heard  over  the  body 
or  center  of  the  heart,  near  the  roots  of  the  great  vessels,  and 
over  the  base  of  the  right  ven- 
tricle, seldom  at  the  apex.  In 
other  words,  it  is  found  usually 
in  the  third  and  fourth  left  in- 
terspaces, where  it  does  not  co- 
incide with  the  areas  of  maxi- 
mum intensity  of  the  organic 
valvular  murmurs.  Of  course, 
it  may  be  heard  over  a  large 
part  of  the  precordium  in  cases 
of  extensive  fibrinous  pericardi- 
tis; often  in  the  second  inter- 
space, and  nearly  as  far  as  the 
left  nipple. 

It  is  circumscribed  rather 
sharply — that  is,  its  audibility 
is  limited  pretty  closely  to  the 
point  of  its  origin — and  it  is 
not  propagated  along  any  blood- 
current. 

RHYTHM. — This  is  the  most  important  physical  sign  to  be  deter- 
mined in  connection  with  the  pericardial  rubbing  sound.  In  the  first 
place,  it  is  notoriously  variable  and  changeable  in  time.  However,  it 
is  mostly  to-and-fro,  systolic-diastolic,  but  may  occur  in  any  portion 
of  these  cardiac  functions;  it  may  accompany  and  overlap,  or  go  be- 
tween, preceding  or  following  either  or  both  heart  sounds,  more  often 
being  interposed  between  than  synchronous  with  them.  Although  most 
frequently  associated  with  ventricular  systole  or  diastole,  sometimes, 
as  I  have  heard  in  two  cases,  one  fatal,  there  may  be  a  triple  friction 
sound  due  to  auricular  systole,  like  the  3 :  4  rhythm  of  waltz  music. 
A  double  sound  may,  so  to  speak,  hug  the  second  sound. 

A  characteristic  feature  of  the  pericardial  murmur  is  its  irregu- 
larity of  rhythmic  relation  to  the  systole  and  diastole,  being  at  one 


FIG.  67. — USUAL  LOCATION  OF  PERICAR- 
DIAL FRICTION  SOUND  AND  FREMITUS. 
(Babcock.) 


310  PHYSICAL    DIAGNOSIS 

time  closer  to  one,  then  in  a  day  or  two  to  the  other  corresponding 
sound. 

INTENSITY. — The  factors  which  influence  the  loudness  of  the  peri- 
cardial  rub  have  diagnostic  value.  The  sound  is  superficial;  seems 
to  be  near  to  the  ear.  The  fact  that  it  actually  is  produced  near  the 
surface  of  the  chest  makes  it  amenable  to  pressure  with  the  stetho- 
scope, its  intensity  being  increased  by  gentle  pressure,  diminished  or 
abolished  by  firm  pressure.  Posture  also  affects  the  loudness  of  a 
pericardial  friction  murmur,  so  that  it  becomes  more  distinct  in  the 
erect,  and  still  more  in  the  forward  bending,  posture;  although  in 
some  cases,  probably  where  the  pericarditis  is  more  apical  and  pos- 
terior, the  reverse  may  be  true.  The  effects  of  respiration  are  likewise 
inconstant,  but  usually  the  sound  is  intensified  by  a  full  inspiration 
whenever  sufficient  to  cause  firmer  apposition  of  the  rubbing  mem- 
branes. 

Broadly  speaking,  the  intensity  of  pericarditic  friction  sounds  de- 
pends upon  (1)  the  properties  of  the  exudate  and  (2)  the  strength 
of  cardiac  action.  A  fresh,  soft,  smooth  fibrinous  deposit,  with  feeble 
force  of  the  heart,  will  give  a  hardly  perceptible  friction  sound;  on 
the  other  hand,  a  chronic,  thick,  hard,  and  rough  deposit,  with  exag- 
gerated cardiao  force,  will  produce  a  loud  and  harsh  murmur.  Peri- 
cardial friction  sounds  vary  in  intensity  from  day  to  day,  as  well  as 
in  precise  location.  In  patients  with  thin  chest  walls  and  a  tumultu- 
ously  pulsating  dilated  right  ventricle,  firm  pressure  with  the  stetho- 
scope in  the  fourth  or  fifth  left  interspace  may  develop  a  rubbing 
sound  which  often  closely  simulates  the  pericardial  friction. 

It  should  be  noted  here  that  a  variety  of  conditions  besides  simple 
fibrinous  pericarditis  may  give  rise  to  friction  sounds.  The  principal 
of  these  are  the  following :  Abnormal  dryness  or  stickiness  of  the  peri- 
cardial serous  surfaces,  as  in  cholera;  milk  spots  on  the  visceral 
(right  ventricle)  pericardium;  tuberculosis,  carcinoma,  and  gumma- 
tous  syphilis  of  the  pericardium ;  calcifications  and  fibrous  roughnesses 
from  arterial  sclerosis  (Gibson). 

DIFFERENTIAL  DIAGNOSIS  BETWEEN  PERICARDIAL  FRICTION 
SOUNDS  AND  ENDOCARDIAL  MURMURS. — This  is  made  by  noting 
especially  the  differences  in  quality,  in  rhythm,  in  constancy  of  loca- 
tion and  intensity,  the  variable,  shifting  position  of  the  pericardial 
murmurs  being  in  marked  contrast  to  the  constancy  of  endocardial 
valve  murmurs.  The  superficial  character  of  friction  sounds,  and 
their  susceptibility  to  pressure  of  the  stethoscope,  are  features.  Other 
points  are  the  temporary  nature  and  irregular  strength  and  time  of 


AUSCULTATION  311 

the  pericardial,  and  the  chronicity  and  regularity  of  the  endocardial 
murmurs. 

Pleuropericardial  Friction  Sounds. — Murmurs  may  be  caused  by 
roughness  of  the  outer  surface  of  the  pericardium,  or  of  that  portion 
of  the  pleura  which  overlaps  the  heart,  or  both.  The  resulting  pleuro- 
pericardial  friction  sounds  are  similar  in  quality  to  the  pericardial. 
They  are  most  frequently  heard  in  the  fourth  and  fifth  interspaces, 
where  the  lingula  of  the  left  lung  is  apposed  to  the  apical  portion  of 
the  heart.  A  distinguishing  feature  of  these  sounds,  which  are  vir- 
tually pleuritic  friction  sounds  in  origin,  is  their  behavior  in  relation 
to  respiration.  The  friction  is  often  heard  only  during  inspiration, 
and  during  the  cardiac  systole ;  and  while  it  may  disappear  when  the 
patient  holds  his  breath,  it  is  only  faintly  audible,  if  at  all,  during 
the  expiratory  act.  It  is  usually  louder  during  a  full  inspiration  than 
an  ordinary  one.  I  have  seen  a  few  cases  in  which  the  sound  was 
heard  as  a  pleuritic  friction,  with  respiratory  rhythm,  during  forced 
breathing,  and  as  a  pericardial  friction  during  quiet  breathing,  with 
the  rhythm  of  cardiac  action  alone  distinct. 

Subphrenic  friction  may  be  produced  by  a  subdiaphragmatic  peri- 
tonitis or  a  diaphragmatic  (phrenic)  pleuritis,  the  sound  being  syn- 
chronous with  the  heart  action,  and  best  audible  at  the  lower  end 
of  the  sternum  and  in  the  interchondral  spaces. 

Pericardial  Splashing  Sounds. — These,  which  may  also  have  a 
churning  quality,  are  heard  if  air  and  fluid  be  present  in  the  peri- 
cardial sac,  as  from  stab  wounds.  The  condition  is  termed  a  hydro- 
or  pi/op»ritinopericardium,  analogous  to  similar  conditions  of  pneumo- 
thorax,  the  heart  acting  as  a  rhythmical  succussion-splash  producer. 
The  sounds  have  been  well  likened,  also,  to  those  caused  by  a  water- 
wheel.  Obviously,  they  continue  while  the  breath  is  held.  Exception- 
ally, such  sounds  may  indicate  the  disturbing  effect  of  cardiac  action 
upon  adjacent  large  pulmonary  cavities  rilled  partially  with  gas  and 
liquid  exudate,  or  upon  a  dilated  stomach.  In  the  latter  case,  the 
sounds  may  have  a  metallic  tone. 

Cog-wheel  respiration,  in  the  majority  of  instances,  is  undoubtedly 
suggestive  of  a  tubercular  deposit  in  the  bronchioles,  and  yet  may 
occur  as  an  accompaniment  of  a  hypertrophied  heart.  In  this  exo- 
cardial  phenomenon  my  experience  tallies  with  the  experience  of 
Gibson.  A  gentleman,  fifty  years  of  age,  of  medium  build  but 
with  muscles  of  iron-like  resistance,  was  considered  a  good  oarsman 
on  the  Schuylkill  Eiver  when  a  young  man.  His  lungs  are  entirely 
sound;  nevertheless,  he  has,  along  with  a  strong,  hypertrophied  heart, 


312  PHYSICAL    DIAGNOSIS 

interrupted  inspiration  over  portions  of  his  left  upper  lobe,  anteriorly. 
It  is  probable  that  a  pleuropericardial  or  cardiorespiratory  murmur 
may  be  confused  with  cog-wheel  respiratory  sound  of  cardiac  causation. 
Crepitations,  or  fine  crackling  or  moist  rales,  may  be  set  up  by 
and  accompany  the  movements  of  the  heart  as  other  extrinsic  mani- 
festations. Thus,  adjacent  to  and  impinging  upon  the  heart,  the 
air-vesicles  and  smaller  bronchi  contain  more  or  less  viscid  secretion; 
or  there  may  be  a  mediastinal  emphysema,  in  all  of  which  these 
adventitious  sounds  occur  in  synchronism  with  the  heart's  movements. 


CHAPTER    XIV 
EXAMINATION  OF   THE  BLOOD-VESSELS 

THE    ARTERIES 

INSPECTION 

IN  connection  with  the  physical  signs  of  diseases  of  the  heart, 
no  rational,  successful,  or  useful  diagnosis  can  be  made  without  a 
careful  consideration  of  the  vascular  phenomena.  The  diagnostic 
value  of  the  evidence  to  be  obtained  by  observation  of  the  cervical 
and  peripheral  vessels  is  a  common  fact  in  the  interpretation  of  car- 
diac conditions.  The  pipes  are  organically,  vitally,  semeiologically 
related  to  the  pump. 

The  Arch  of  the  Aorta  and  the  Larger  Arteries. — Visible  pulsa- 
tion along  the  course  of  the  aortic  arch  is  usually  significant  of 
aneurism,  especially  if  accompanied  with  swelling.  If  the  pulsation 
is  seen  to  the  right  of  the  sternum,  the  ascending  portion  is  involved. 
When  the  manubrium  or  the  suprasternal  notch  pulsates,  the  trans- 
verse portion  of  the  arch  is  affected.  It  should  not  be  forgotten, 
however,  that  not  all  aortic  pulsations  observed  are  necessarily  ab- 
normal; as  in  the  episternal  notch,  it  may  be  due  to  a  high  location 
of  the  arch,  rarely  to  mere  old  age.  On  the  other  hand,  the  aortic 
pulsation  may  be  due  to  retraction  of  the  lung.  Aneurismal  pulsa- 
tions are  invariably  systolic.  Sometimes  a  pulsation  in  the  second 
right  interspace  may  mean  dilation  of  the  commencement  of  the 
aorta,  associated  with  aortic  insufficiency  and  marked  hypertrophy 
of  the  left  ventricle;  but  it  usually  has  a  more  diffuse,  wavy  charac- 
ter instead  of  the  finer,  shorter,  more  circumscribed  aneurismal 
impulse. 

The  pulmonary  artery  may  be  seen  to  pulsate  in  retraction  of  the 
left  lung  from  fibroid  phthisis  or  chronic  pleural  adhesions.  In  a 
case  of  cerebrospinal  meningitis,  in  a  boy  of  six  years,  I  once  wit- 
nessed the  development  of  acute  endocarditis  as  a  complication,  with 
decided  pulsation  over  the  pulmonary  artery,  palpable  as  well  as  visi- 
ble, and  accompanied  with  a  systolic  murmur  heard  best  in  the  same 

313 


314  PHYSICAL    DIAGNOSIS 

region.  Aneurismal  pulsation  of  this  artery  may  also  occur,  but  it 
is  rare. 

The  innominate  artery  may  give  rise  to  visible  pulsation  near  the 
right  sternoclavicular  articulation,  and  oven  to  some  Imlging  owing 
to  aneurism,  or  possibly  to  disturbance  from  involvement  by  aneurism 
of  the  aortic  arch. 

The  carotid  arteries  show  a  slight  movement  of  pulsation  above 
the  clavicles  in  many  healthy  persons.  Decided  visible  pulsation  of 
the  carotids  may  indicate  nervous  excitement  or  emaciation  without 
any  cardiac  abnormality. 

Marked  throbbing  in  the  neck,  however,  is  most  typically  caused 
by  the  combination  of  cardiac  hypertrophy  and  aortic  insufficiency; 
in  fact,  it  is  a  common  phenomenon  in  most  instances  of  imperfect 
filling  of  the  arterial  system  with  relaxation  or  dilation  of  the  vascu- 
lar walls,  as  is  met  with  in  anemia,  the  hypoplasia  of  chlorosis,  ex- 
ophthalmic goiter,  etc.  Arteriosclerosis  may  also  so  affect  these 
arteries  as  to  produce  visible  pulsations,  owing  to  the  prominence 
of  the  thickened,  rigid,  tortuous  walls. 

Abnormal  pulsations  of  the  other  arteries  are  due  to  the  same 
causes  that  have  just  been  enumerated.  It  is  in  aortic  re  gurgitation, 
however,  that  the  most  distinctive  pulsations  of  the  principal  arteries 
are  noticeable.  We  find  this  especially  true  of  the  subclavian,  axil- 
lary, brachial,  and  radial  arteries;  less  so  of  the  ulnar,  femoral,  an- 
terior and  posterior  tibial,  and  dorsalis  pedis  arteries.  The  mode  of 
production  may  be  indicated  as  follows:  The  sharp,  exaggerated  rise 
of  the  pulse-wave  is  due  to  the  hypertrophied  left  ventricle,  and  the 
inelastic  vascular  walls  usually  associated.  As  soon  as  cardiac  dias^ 
tole  begins  the  intravascular  pressure  is  suddenly  released,  aided  by 
the  regurgitating  current  of  blood  into  the  left  ventricle,  thus  making 
the  pulsation  manifest  by  the  extreme  amplitude  of  rise  and  fall. 
Prominence  of  the  temporal  artery  and  of  its  pulsation  is  a  common 
observation  in  those  more  or  less  old  people  who  show  the  vascular 
changes  of  fibrous  thickening.  Not  infrequently  one  may  notice  in- 
equalities in  the  course  of  a  sclerosed  artery,  due  to  the  collection 
of  lime  salt  deposits.  Sometimes,  also,  a  lateral  movement  of  a 
prominent  and  tortuous  brachial  artery  at  the  elbow,  or  of  a  tem- 
poral artery,  may  be  observed  as  well  as  the  vertical  pulsation. 

The  Abdominal  or  Descending  Aorta. — This  is  seldom  seen  to 
pulsate  in  the  healthy  individual,  except  temporarily  from  exertion 
and  excitement.  Reference  has  already  been  made  to  aortic  pulsa- 
tion in  the  epigastrium;  its  production  by  immediate  disease,  as 


EXAMINATION    OF    THE    BLOOD-VESSELS         315 

aneurism,  or  by  transmission  through  an  overlying  p}4oric,  pancre- 
atic, he'patic,  mesenteric,  or  other  tumor.  In  distinct  contrast  to  the 
circumscribed  pulsation  of  an  abdominal  aortic  aneurism  is  the  diffuse 
pulsation — violent  it  may  be — of  a  large  portion  of  the  vessel.  This 
is  characteristic  of  many  patients  who  are  neurotic,  hysteric,  or  neu- 
rasthenic, and  who  suffer  reflexly  from  various  complaints,  as  chronic 
gastro-intestinal  catarrh,  movable  kidney,  ptosis  of  the  abdominal 
organs,  ovarian  disorders,  tuberculosis,  peritonitis,  and  the  like. 

PALPATION 

The  Aorta.— This  great  vessel  is  not  palpable  normally,  except  in 
certain  anomalous  cases  of  high  position  of  the  arch,  when  its  pulsa- 
tions may  be  felt  in  the  episternal  notch  by  making  deep  pressure 
downward  behind  the  sternum.  In  acute  or  chronic  dilation  (diffuse), 
with  or  without  aortitis,  the  aorta  may  be  felt  in  the  right  first  and 
second  interspaces,  and  if  the  transverse  portion  of  the  arch  is  in- 
volved, also  over  the  manubrium  as  a  transmitted  impulse.  It  is  in 
the  diagnosis  of  aneurism  that  palpation  has  decided  confirmatory 
value,  noting  the  area,  force,  and  expansile  character  of  the  pulsation, 
thrill,  and  diastolic  shock.  Here  may  be  described  also  the  palpatory 
sign  of  thoracic  aneurism  known  as  the  "  tracheal  tug."  It  is  elicited 
by  the  physician  standing  behind  the  seated  patient,  whose  head  is 
bent  well  back  and  chin  elevated.  The  examiner  then  inserts  the 
tips  of  both  index  fingers  under  the  lower  edge  of  the  cricoid  car- 
tilage, which  is  gently  raised  by  them  (Ewart),  when,  if  aortic  aneu- 
rism be  present,  an  unmistakable  downward  tug  is  felt  with  each 
cardiac  systole.  Tracheal  tugging  occurs  only  when  the  aneurism  is 
so  situated  and  connected  with  the  transverse  portion  of  the  arch 
of  the  aorta  that  it  presses  downward  upon  the  trachea  at  its  bifur- 
cation. 

The  pulmonary  artery  or  second  left  interspace  region  may  be 
the  seat  of  pulsations  that  may  be  palpated.  Here,  near  the  sternum, 
may  sometimes  be  felt,  an  instant  later  than  the  apical  impulse,  a 
circumscribed  pulsation  or  diastolic  shock,  due  to  a  sharp  recoil  upon 
the  pulmonary  valve  leaflets  from  heightened  pressure  in  the  pulmo- 
nary circulation,  and  is  thus  an  indication  of  hypertrophy  of  the 
right  ventricle,  especially  noticeable  if  there  is  simultaneous  retrac- 
tion of  the  anterior  border  of  the  left  lung.  Such  marked  hyper- 
trophy of  the  right  ventricle  is  usually  the  result  of  mitral  stenosis. 

The  palpable  signs  of  the  other  arteries  and  their  pulsations  may 


316  PHYSICAL   DIAGNOSIS 

be  included  in  the  consideration  of  the  traditionally  and  commonly 
and  quite  appropriately  selected  radial  artery  and  pulse.  As  an  index 
of  the  cardiac  condition  and  of  vasomotor  tone,  the  anatomic  situation 
and  practical  convenience  of  access  of  the  radial  artery  make  it  suffi- 
cient and  satisfactory,  although  on  occasion  the  carotid  and  temporal 
arteries  serve  a  useful  purpose. 

The  Pulse 

In  these  days  of  instruments  and  methods  of  precision  in  the 
examination  of  the  heart,  much  less  attention  is  being  paid  to  the 
pulse  in  the  clinical  instruction  of  medical  colleges  than  should  be. 
In  practise,  however,  it  is  doubtful  whether  the  busy  physician  in 
private  or  hospital  work  fails  to  acquire  quickly  and  comprehensively 
most  important  data  which,  although  bearing  upon  the  condition  of 
the  heart,  could  not  be  determined  so  promptly  \)j  an  examination 
of  that  organ  itself.  This  is  especially  true  of  emergencies,  and  in 
multitudes  of  instances  where  judgment  and  skill  in  diagnosis,  prog- 
nosis, and  treatment  are  urgent  factors.  Hence  it  is  that  training 
in  taking  the  pulse  can  never  be  too  full,  constant,  and  diligent,  so 
that  the  most  exquisite  sensitiveness  of  touch  may  be  developed  in 
conjunction  with  related  clinical  and  pathologic  knowledge — feeling 
with  the  brain  as  well  as  with  the  fingers.  There  are  several  instru- 
mental auxiliaries  in  ascertaining  the  character  of  the  pulse,  such  as 
the  sphyg  mo  graph,  for  making  graphic  pulse  tracings,  and  the  spliiifj- 
momanometer  and  tonometer,  for  determining  the  blood-pressure ;  and 
while  both  are  scientifically  and  practically  valuable  in  diagnosis, 
they  can  never  take  the  place  of  the  convenient,  well-trained,  sentient 
finger-tips. 

Method  of  Examining  the  Pulse. — The  position  of  the  patient's 
body  is  important,  especially  as  it  influences  the  frequency  of  the 
pulse.  All  muscular  constraint  must  be  forestalled  by  putting  him 
at  ease  in  a  reclining  or  sitting  posture.  The  arm  whose  radial  pulse 
is  to  be  palpated  should  be  allowed  to  rest  upon  the  side  of  the  bed 
or  couch,  a  table,  or  chair  support,  or  should  be  held  by  the  exam- 
iner's other  hand.  If  the  patient's  left  radial  artery  is  to  be  examined, 
the  observer  stands  or  sits  to  the  left,  and  employs  his  left  index, 
middle,  and  ring  fingers,  or,  as  I  often  prefer,  the  first  two  of  these, 
with  their  tips  just  inside  and  above  the  styloid  process  of  the  radius, 
the  patient's  wrist  being  held  in  a  semiprone  position.  For  the  right 
artery,  the  physician  palpates  similarly  with  the  right  hand  while  at 
the  patient's  right  side.  Exceptional  conditions  of  convenience,  neccs- 


EXAMINATION    OF    THE    BLOOD-VESSELS         317 

sity,  adaptability,  and  the  personal  equation  may  alter  or  reverse  this 
method.  When,  as  should  always  be  done,  both  radials  are  examined 
simultaneously,  the  observer  stands  in  front  of  the  patient,  using  his 
right  hand  for  the  right  artery,  and  his  left  for  the  left.  The  technic 
here  given  affords  the  accomplishment  of  placing  the  index  finger 
proximally — that  is,  nearest  to  the  heart — and  thus  enables  this  most 
sensitive  finger  to  regulate  the  pressure  upon  the  artery,  the  effects 
of  which  may  then  be  appreciated  by  the  other  fingers  (Gibson). 
The  palpating  pressure  should  at  first  be  light.  Not  only  should 
both  arteries  be  palpated,  at  least  on  the  first  examination,  for  the 
estimation  of  any  possible  asymmetries  of  pulsation — to  be  referred 
to  later — but  also  to  discover  any  anomalous  position.  For  it  is  not 
uncommon  to  find  the  radial  artery  winding  around  the  upper  part 
of  the  styloid  process  of  the  radius  to  the  back  of  the  hand,  leaving 
the  bony  base  of  the  artery  in  front  without  pulsation,  or  with  a 
slight,  deceptive  pulsation,  produced  probably  by  the  superficial  volar 
artery. 

Other  points  in  the  technic  will  be  indicated  as  the  conditions 
to  be  ascertained  specifically  are  described  seriatim. 

Phenomena  to  be  Observed. — It  is  well  to  adopt  a  habitual  order 
of  procedure  in  studying  the  details  of  the  artery  and  pulse.  Thus 
we  may  gain  a  threefold  impression,  mainly:  (1)  The  condition  of 
the  artery — its  walls;  (2)  the  condition  of  its  blood-supply — its  ful- 
ness; (3)  the  character  of  the  pulse-wave — its  pulsatory  dilation  and 
contraction. 

In  palpating  the  pulse,  it  will  be  noticed  that  we  determine  three 
important  factors  intimately  connected  with  heart  affections:  The 
elasticity  of  the  arterial  system  is  inferred;  the  cardiac  action,  and 
the  resistance  in  the  arteries  and  capillaries,  each  of  these  two  latter 
factors  influencing  both  the  second  and  third  impressions  indicated 
above. 

( 1 )  THE  ARTERIAL  WALLS.  Technic. — By  digital  pressure  a  little 
above  the  palpating  region,  the  radial  artery  may  be  emptied,  and 
rolled  under  the  other  fingers  by  slipping  the  skin  over  it  to  and  fro, 
at  the  same  time  pressing  the  vessel  gently  against  the  bone.  In  this 
way  the  size  or  caliber  of  the  artery,  and  the  condition  of  its  walls, 
may  be  felt.  The  normal  size  of  the  radial  arteries  may  vary  de- 
cidedly in  different  individuals,  and  its  determination  must  be  largely 
a  matter  of  judgment  based  upon  many  observations,  and  upon  con- 
siderations involved  in  the  build  of  each  person.  The  estimation 
must  be  made  from  the  sensations  derived  between  the  pulsations  in 


318  PHYSICAL    DIAGNOSIS 

order  to  be  truly  representative  of  the  actual  arterial  caliber.  One 
may  note  small  arteries  in  a  large,  stout  man,  or  large  arteries  in  a 
lean  man,  exceptionally,  but  usually  we  find  large-sized  arteries  in 
individuals  of  large  build  and  large  hearts,  and  smaller  ones  in  those 
of  small  musculature  and  stature. 

Pathologically  we  seldom  meet  with  a  radial  artery  which  can  be 
denominated  as  oversized.  It  may,  however,  be  found  in  certain 
persons  of  obese  habit,  inclined  to  pallor  rather  than  to  plethora 
(the  "lymphatic  temperament"  of  the  older  writers),  and  with 
a  notable  flabbiness  of  the  walls  as  an  associated  sign.  This  is  fre- 
quently an  indication  of  accompanying  cardiac  weakness  or  lack  of 
myocardial  tone  and  vigor  from  hypoplasia.  On  the  other  hand, 
abnormally  small  arteries  are  more  commonly  met  with,  often  as 
congenital  conditions,  when  they  may  be  mistaken  for  weak,  small, 
thready  pulse-waves,  which,  of  course,  do  occur  with  them,  for  obvi- 
ous anatomic  reasons,  and  not  because  of  diminished  heart  power. 
Hence,  as  Cabot  points  out,  it  is  important  to  distinguish  such  a 
small  pulse-wave  from  a  really  weak  pulse.  The  wiry,  contracted 
artery  of  chronic  lead-poisoning,  etc.,  may  more  readily  be  palpated 
between  the  pulse-beats  because  of  its  resistant  qualities. 

The  normal  physical  condition  of  the  arterial  walls  gives  the  pal- 
pating finger  the  feel  of  resiliency  or  elasticity  with  slight  or  moderate 
pressure.  It  should  be  remarked,  however,  that  in  running  the  finger 
along  the  artery  it  is  difficult  to  feel  between  pulsations  except  in  a 
very  thin  wrist,  because  of  the  fact  that  the  normal  walls  are  soft  and 
yielding  as  well  as  elastic. 

The  principal  abnormality  is  due  to  atheromatous  degeneration 
and  thickening,  which  give  rise  to  tortuosity,  hardness,  rigidity,  and 
varicosity  of  the  walls.  The  discovery  of  one  or  more  of  these  signs 
in  the  radial  artery  is  confirmatory  of  a  widely  distributed  arterio- 
sclerosis of  the  peripheral  arteries,  and  usually  of  some  hypertrophy 
of  the  left  ventricle.  The  radial  may  simply  feel  unduly  firm  and 
stiff,  with  little  or  no  tortuosity,  as  a  result  of  fibrous  thickening, 
and  may  thus  be  rolled  under  the  fingers  like  a  cord.  Sometimes 
several  inches  of  the  artery  may  be  traced  up  the  forearm,  the  pulse- 
wave  passing  under  the  fingers  as  a  distinct  worm-like  movement. 
When  the  artery  feels  varicose  or  "  beaded,"  as  if  girded  at  short 
intervals  with  hard  rings,  calcification,  or  the  deposit  of  lime  salts, 
is  present.  Strictly,  the  varicosities  are  due  to  the  bellyings  between 
the  calcified  constrictions.  In  aggravated  cases  the  calcification  is 
so  diffuse  and  the  hardening  so  continuous  as  to  give  rise  to  the 


EXAMINATION    OF    THE    BLOOD-VESSELS         319 

well-known  term,  "  pipe-stem  arteries."  Here  the  pulse  may  be  prac- 
tically obliterated,  so  as  to  cause  the  artery  to  simulate  a  tendon. 
Hardening  of  the  arteries  must  not  be  confounded  with  increased 
tension  of  pulse  (see  later). 

(2)  ARTERIAL  VOLUME,  OR  THE  BLOOD-SUPPLY. — This  may  be 
estimated  by  palpating  the  artery  at  its  systole — that  is,  between  the 
pulse-beats — as  in  the  case  of  the  vessel  itself.     Indeed,  the  sense  of 
fulness  which  the  radial  may  possess  is  very  like  that  of  its  caliber, 
with  this  difference,  that  whether  the  artery  be  large  or  small,  its 
sense  of  fulness  is  accompanied  by  a  greater  resistance  or  tension  than 
otherwise.     A  full  artery  (arteria  plena)  is  to  be  discriminated  from 
a  full  pulse,  and  a  comparatively  empty  artery  (arteria  vacua)  from  an 
empty  pulse;  as  a  high-tension  pulse,  with  small  wave  amplitude, 
may  yet  occur  in  a  full  artery,  and  a  full  pulse  is  often  felt  in 
certain  wasting  diseases  where  the  actual  blood-supply  is  markedly 
deficient. 

The  pathologic  states,  then,  which  give  rise  to  these  two  types  of 
arterial  fulness  are  three:  (a)  abnormal  quantity  of  blood,  either 
plethora  or  anemia;  (&)  degree  of  cardiac  power,  strong  or  weak; 
(c)  resistance  in  the  arterioles,  great  or  slight,  arteriosclerosis  and 
chronic  interstitial  nephritis  being  examples  of  the  first,  especially 
in  the  early  stages,  the  relaxation  of  malnutrition,  chronic  wasting 
diseases — as  cancer — some  acute  febrile  diseases,  and  aortic  incompe- 
tency,  examples  of  the  second. 

(3)  CHARACTER  OF  THE  PULSE. — Ordinarily  the  pulse- waves  are 
studied  first   (and  these  counted  per  unit  of  time),  the  preceding 
points  being  left  until  later.     There  should  be  noted:  (a)  The  rate 
or  frequency;  (b)  the  rhythm  or  regularity;  (c)  the  quality  or  char- 
tictcr;  (d)  the  symmetry. 

The  normal  pulse,  obviously,  has  all  of  these  elements,  individually 
correctly  developed  and  collectively  relatively  balanced.  In  short, 
the  pulsations  should,  to  be  normal,  have  a  rate  variable  only  within 
certain  limits — a  regular  rhythm — and  a  moderate  and  uniform 
volume,  force,  form,  duration,  and  tension  or  sustained  pressure. 

(a)  The  Rate  of  the  Pulse. — The  normal  pulse-rate  varies  within 
certain  limits,  and  according  to  certain  influences  to  be  mentioned 
shortly.  The  average  frequency  in  the  adult  male,  however,  is  72 
per  minute;  in  the  female,  about  74,  although  many  women  have  a 
normal  rate  of  78  or  80  pulse-beats  per  minute.  The  personal  idio- 
syncrasies ordinarily  met  with  cause  a  pulse-rate  seldom  under  60  or 
over  80  in  those  of  middle  life.  In  the  youngest  infants  the  pulse 


320  PHYSICAL   DIAGNOSIS 

frequency  is  normal  at  alxnit  140  beats  to  the  minute;  when  one  year 
of  age,  120  to  130;  at  three  years,  100;  at  the  fifth  and  sixth  years, 
from  90  to  95.  The  normal  pulse  is  quite  susceptible  to  acceleration 
from  exertion,  excitement,  anxiety,  and  other  emotional  states,,  after 
meals,  during  the  later  hours  of  the  day,  in  hot  weather,  in  the  erect 
attitude,  after  forced  breathing,  etc.  The  pulse-rate  may  be  normally 
slow  as  a  congenital  condition,  in  old  age,  and  immediately  after 
childbirth. 

It  is  not  within  the  province  of  this  book  to  enumerate  even  the 
multitude  of  pathologic  conditions  of  which  increased  or  decreased 
frequency  of  the  pulse  is  symptomatic:  the  fevers,  inflammations, 
intoxications,  neuroses,  degenerations,  and  various  functional  and 
organic  affections  of  the  cerebrospinal  system,  thorax,  abdomen,  and 
so  on.  It  will  suffice  to  point  out  briefly  the  cardiac  disorders  which 
cause  abnormal  pulse-rates. 

(i)  Increased  Frequency  (Pulsus  frequens). — The  pulse  may 
be  increased  in  frequency  in  all  forms  of  valvular  disease  except  in 
aortic  stenosis;  in  cardiac  weakness  or  dilation  (heart-failure),  from 
whatever  cause;  in  the  cardiac  neuroses,  such  as  nervous  palpitation 
from  tobacco,  tea,  alcohol,  and  venereal  excesses,  exophthalmic  goiter ; 
and  in  paralysis  of  the  vagus  or  irritation  of  the  sympathetic  nerves 
or  of  the  intracardiac  ganglia.  The  various  forms  of  simple  increase 
of  rapidity  of  the  heart,  with  corresponding  pulse-rate,  are  included 
under  the  term  tachycardia.  Extremely  rapid  pulse  is  a  character- 
istic of  those  more  essential,  sudden,  alarming  attacks  known  as  a 
paroxysmal  tachycardia,  lasting  from  a  few  minutes  to  several  days. 
The  pulse-rate  may  go  as  high  as  200  per  minute,  or  even  more. 
This  affection  may  be  due  to  coronary-artery  disease,  or  to  areas  of 
necrosis  in  the  myocardium.  Similarly,  in  angina  pectoris  there  is 
decided  increase  in  pulse-rate  frequency.  The  pulse  also  reflects  the 
cardiac  condition  as  affected  by  various  thoracic  and  abdominal  dis- 
eases, by  anemia,  tuberculosis,  rheumatoid  arthritis,  etc.  In  the 
chronic,  apyrexial  diseases  of  the  heart,  where  the  valvular  and  myo- 
cardial  lesions  predominate,  the  rate  of  the  pulse  varies  from  80  to 
120  beats  per  minute. 

(ii)  Decreased  Frequency  (Pulsus  ranis}. — Abnormally  slow 
pulse  is  the  direct  result  of  slow  heart — bradycardia  or  brachycardia 
— or  a  rate  usually  below  60.  It  should  be  remembered  that  the 
pulse  may  be  normally  infrequent  as  a  personal  idiosyncrasy,  or  even 
a  family  characteristic.  A  rate  of  40  or  under  is  generally  consid- 
ered of  very  grave  significance.  In  an  elderly  woman  with  cardiac 


EXAMINATION    OF    THE    BLOOD-VESSELS         321 

dilation  due  to  mitral  insufficiency,  a  fatal  attack  of  influenza  super- 
vening, I  noted  a  pulse-rate  of  26  beats  per  minute.  In  fact,  during 
the  prevalence  of  severe  influenzal  epidemics  in  the  last  decade  of  the 
nineteenth  century,  bradycardia  was  a  frequent  complication  and 
temporary  sequel. 

Among  the  other  maladies  which  are  chiefly  responsible  for  the 
bradycardial  origin  of  slow  pulse,  the  following  may  be  mentioned: 
(a)  Cardiac  disease,  such  as  affects  principally  the  myocardium — 
fatty  degeneration,  especially  when  due  to  atheroma  of  the  coronary 
arteries;  chronic  fibroid  myocarditis,  and  sclerotic  stenosis  of  the 
aortic  orifice,  (b)  Increased  arterial  tension  and  resistance  from 
poisonous  substances  circulating  in  the  blood  and  affecting  the  car- 
diac centers  or  ganglia,  as  in  auto-intoxication  from  chronic  digestive 
disorders,  jaundice  of  hepatic  origin,  chronic  Bright's  disease  (chronic 
uremia) ;  also  from  chronic  lead,  alcohol,  and  illuminating-gas  poison- 
ing, (c)  Cerebral  and  meningeal  diseases  which  increase  the  intra- 
cranial  pressure,  and  consequent  irritation  of  the  vagus,  as  tumors, 
effusions,  hemorrhages ;  or  there  may  be  peripheral  pressure  upon  this 
nerve  or  the  cervical  cord  from  tumors,  injuries,  and  the  like,  (d) 
Essential  bradycardia,  a  persistent  condition  for  years,  supposed  to 
be  without  any  definite  lesion,  but  often  really  due  to  sclerosis  of  the 
coronary  arteries,  or  perhaps  of  the  medullar  arteries  about  the  vagus 
center.  When  associated  with  epileptiform  attacks  the  condition  is 
known  as  the  Stokes- Adams  syndrome,  (e)  Myxedema,  melancholia, 
the  convalescent  stage  of  the  acute  infectious,  febrile  diseases,  asth- 
matic paroxysms,  and  inanition  may  all  cause  infrequent  pulse.  Care 
should  be  exercised  not  to  mistake  an  intermittent  for  a  slow  pulse 
because  of  the  untransmitted  pulsations.  This  error  may  be  avoided 
by  auscultating  the  heart  simultaneously  with  radial  palpation. 

(b)  Rhythm  of  the  Pulse. — The  normal  pulse-waves  succeed  each 
other  with  complete  regularity  in  respect  to  time  of  contact  with  the 
finger  and  of  interval  between  the  waves ;  also  in  respect  to  force  and 
other  qualities  pertaining  to  the  successive  beats.  Again,  however, 
we  meet  with  individuals  occasionally  whose  pulse-beats  manifest  slight 
irregularities  of  rhythm,  but  in  whom  not  the  least  evidence  of  cardiac 
or  reflex  origin  is  discoverable.  Nevertheless,  it  may  be  found  some 
time  that  these  apparent  idiosyncrasies  may  prove  to  be  congenital, 
autotoxic,  or  neurotic  in  causation.  Physiologic  deviations  may  occur 
in  old  age,  after  severe  exertion,  and  during  intense  mental  excite- 
ment. I  have  observed  in  several  persons  a  slight  acceleration  near 
the  end  or  just  after  the  height  of  the  inspiratory  act  for  two  or 
23 


322  PHYSICAL    DIAGNOSIS 

three  beats,  the  rate  subsiding  during  the  pause  between  the  respira- 
tions— a  sort  of  regular  irregularity. 

Arhythmia  signifies  virtually  a  disturbance  of  the  nervous  mech- 
anism governing  the  automatic  contractions  of  the  heart.  The  causes 
of  such  deranged  innervation  may  be  grouped  into  two  classes :  those 
which  produce  intermittency  of  the  pulse  and  those  which  produce 
specific  irregularity. 

Intermittent  pulse  (pulsus  inter  mitt  ens,  or  deficiens)  means  one 
dropped  beat  at  certain  intervals,  which  may  be  regular  or  irregular. 
That  is,  the  heart  may  skip  a  beat  after  two  contractions  (pulsns 
big  e  minus) ,  or  after  three  (pulsus  trigeminus),  in  regular  sequence; 
or  the  intervals  of  pulsations  may  range  from  three  to  twenty  or  more 
— seven,  then  four,  then  ten,  and  so  on  irregularly  with  the  intermis- 
sions. When  the  intermission  is  due  to  a  real  pause  in  the  cardiac 
action,  it  is  termed  a  deficiens  pulse;  when  due  simply  to  an  occasional 
weak  contraction  of  the  heart  (determined  by  auscultation),  as  an 
intermittens  pulse.  Closely  related  to  the  deficient  and  intermittent, 
the  bigeminal  and  trigeminal  pulses,  and,  as  Vierordt  says,  standing 
somewhat  between  these  and  complete  irregularity,  is  the  intercalated 
or  intercurrent  pulse  (pulsus  intercidens} .  It  is  an  appended  instead 
of  a  suspended  pulsation,  suddenly  and  immediately  following  two  or 
more  regular  pulsations,  the  last  one  of  which  may  be  slightly  weaker 
than  the  other  ones,  and  itself  followed  by  a  slight  but  distinct  pause. 
This  type  of  pulse  is  usually  the  evidence  or  premonition  of  serious 
myocardial  weakness. 

Suspended  or  intermittent  pulse  is  not  characteristic  of  any  disease 
or  condition,  and  may  be  present  without  any  subjective  knowledge 
by  the  patient  as  affecting  his  health.  It  may  be  habitual,  a  consti- 
tutional peculiarity,  or  the  manifestation  of  a  neurosis,  or  of  coffee, 
tea,  tobacco,  or  digitalis  intoxication.  It  may  disappear  during  fever 
or  temporary  acceleration  of  the  heart  from  various  causes.  Prac- 
tically it  is  never  as  serious  a  sign  as  true  irregularity,  and  yet  does 
accompany,  sometimes,  such  organic  conditions  as  valvular  disease, 
especially  mitral,  and  chronic  myocarditis,  with  the  patient  at  rest, 
but  is  apt  to  turn  to  genuine  irregularity  with  the  patient  about  and 
under  the  stress  of  broken  compensation. 

Irregular  pulse  (pulsus  inequalis),  here  dealt  with  as  to  time  or 
as  a  true  arhythmia,  pertains  also  to  quality,  including  volume  and 
force  or  pressure  of  pulse-wave,  to  be  described  shortly.  It  is  charac- 
terized by  irregularity  of  interval  between  the  succession  of  pulsa- 
tions, and  of  the  rate  or  rapidity  of  their  succession.  That  is,  the 


EXAMINATION    OF    THE    BLOOD-VESSELS         323 

time  between  some  of  the  pulse-beats  differs  and  varies  in  length 
from  others,  or  they  may  follow  each  other  in  fast,  and  again  in 
slow  time. 

Although  a  pulse  of  irregular  time  may  occur  in  some  elderly 
persons  of  apparently  good  health,  in  infancy  and  at  puberty,  after 
overexertion  or  dissipation,  in  the  majority  of  cases  it  probably  means 
myocardial  degeneration,  with  or  without  mitral  (especially  stenosis) 
or  aortic  disease,  sclerosis  of  the  coronary  arteries,  or  some  grave 
involvement  of  the  nervous  cardiac  mechanism  from  toxemia — diph- 
theric, alcoholic,  theic,  diabetic,  therapeutic  (digitalis),  uremic,  etc. 
In  the  variety  of  arhythmia  known  as  tremor  or  delirium  cordis,  a 
part  of  the  irregularity  is  due  to  a  paroxysmal,  rapid  fluttering  action 
of  the  heart  reflected  in  the  pulse  action,  and  may  be  found  associated 
with  syncope,  gastro-intestinal  disorders  in  which  flatulence  is  an 
aggravating  symptom,  and  with  the  later  stages  of  fatal  cardiac  con- 
ditions, especially  the  myocarditic  in  gouty,  obese,  and  atheromatous 
subjects. 

(c)  The  quality  of  the  pulse  really  embraces  the  most  important 
and  diagnostically  significant  of  the  phenomena  to  be  palpated.  Thus 
we  study  (i)  the  force  or  compressibility;  (ii)  the  volume  or  size; 
(iii)  the  tension  or  elasticity;  (iv)  the  shape  or  form  of  the  pulse- 
wave;  (v)  the  equality  or  regularity  of  the  pulsations  as  to  these 
attributes. 

(i)  The  force  of  a  pulsation  is  an  index  of  heart  strength,  as 
tension  (iii)  is  of  arterio-capillary  resistance.  It  is  determined  by  the 
degree  of  finger  pressure  required  to  obliterate  the  pulse-wave.  The 
technic  is  as  follows:  Palpating  with  two  fingers,  the  index  and 
middle,  while  pressing  moderately  and  steadily  with  the  proximal 
finger  (nearer  the  heart),  with  the  other  (distal)  the  force  or  com- 
pressibility is  estimated.  If  with  such  pressure  the  pulse-waves  are 
obliterated,  the  pulse  is  spoken  of  as  weak  or  compressible;  if  dis- 
tinctly felt,  as  strong  or  incompressible. 

Allowance  must  be  made  in  those  having  wrists  well  padded  with 
fat,  as  the  pulse  strength  may  be  quite  normal  in  fact,  although  more 
easily  obliterated  by  moderate  external  pressure. 

Abnormal  increase  in  the  force  of  the  pulsations  of  the  radial, 
which  may  be  temporary  or  chronic,  indicates  exaggerated  ventricular 
systole,  and  therefore  the  muscular  power  and  activity  of  the  heart — 
usually  an  hypertrophy. 

On  the  other  hand,  muscular  cardiac  debility  is  indicated  by  a 
compressible  pulse,  as  is  found  in  fatty  degeneration  and  dilation. 


324  PHYSICAL    DIAGNOSIS 

As  the  actual  strength  of  the  pulsr-wavo  is  closely  related  to  and 
conditioned  by  the  arterial  tension,  practically  the  estimation  of  the 
force  or  compressibility  must  culminate  in  a  balanced  judgment  upon 
a  careful  consideration  of  the  two  factors — cardiac  and  vascular — in 
combination.  Of  course,  the  greatest  degree  of  intraradial  pressure 
will  be  noted  where  hypertrophy  of  the  left  ventricle  and  intrinsic 
hypertension  of  the  arterial  walls  exist  together.  The  force  of  the 
pulsations  is  but  slightly  dependent  upon  the  amount  of  blood  in 
the  arteries. 

A  difference  in  the  strength  of  the  radial  pulse  as  the  arms  are 
raised  and  lowered,  comparing  one  side  with  the  other,  as  pointed 
out  by  Sorgo,  may  be  indicative  of  traction  upon  the  subclavian  artery 
by  the  pathologic  apex  of  a  tuberculous  lung. 

(ii)  The  size  of  a  pulse- wave  (volume  of  the  pulse)  also  depends 
upon  the  two  factors  mentioned  just  before,  namely,  the  force  of  the 
myocardial  systole  and  the  tension  of  the  arterial  walls.  The  ampli- 
tude of  each  pulse-wave  is  estimated  by  the  amount  of  diametric 
expansion  palpated :  this  may  be  large,  medium,  or  small. 

Larger  pulse  (pulsus  magnus)  than  normal  may  be  associated  with 
plethora,  hypertrophy  of  the  left  ventricle,  and  relaxed  conditions  of 
the  arterial  walls.  The  large  pulse  is  observed  best  in  cases  of  cardiac 
hypertrophy  accompanied  with  soft,  large,  weak  walls  of  the  vessels. 
This  may  often  be  found  in  cases  of  aortic  incompctency,  where  the 
left  ventricle  is  usually  enormously  enlarged  and  the  arterial  walls 
flabby  and  relaxed.  Two  exceptions  to  the  influence  of  cardiac  hyper- 
trophy upon  the  size  of  the  pulse-waves  should  be  noted.  In  mitral 
regurgitation  the  pulse  may  be  medium  or  small  in  volume,  notwith- 
standing the  hypertrophy,  because  with  each  systole  part  of  the  blood 
in  the  left  ventricle  leaks  back  into  the  left  auricle.  Again,  in  aortic 
stenosis,  the  narrowed  orifice  prevents  even  the  hypertrophied  ventricle 
from  forcing  the  normal,  full  volume  into  the  aorta.  Abnormally 
large  pulse  is  also  observed  in  many  febrile  conditions  (bounding 
pulse) ;  temporarily  from  the  debilitating  effects  of  hot,  humid 
weather,  and  in  some  persons  affected  with  obesity,  tuberculosis,  etc., 
before  decided  cardiac  weakness  has  supervened. 

Abnormally  small  pulse  (pulsus  parvus)  occurs  in  cases  of  cardiac 
weakness  and  constriction  of  the  arteries.  By  contrast  with  large 
pulse,  this  has  already  been  referred  to  in  connection  with  aortic 
stenosis  and  mitral  regurgitation.  In  mitral  stenosis  we  have  a  small 
pulse  because  of  inability  of  a  sufficient  quantity  of  blood  entering 
the  left  ventricle  to  be  propelled  into  the  aorta,  and  the  weak,  atrophic 


EXAMIXATIOX    OF    THE    BLOOD-VESSELS         325 

condition  of  the  ventricle  itself,  due  to  this  very  fact  of  lack  of 
stimulus  and  work,  and  the  consequent  partial  disuse.  A  small  or 
"  thready  "  pulse  may  be  associated  with  aneurism  of  the  aorta,  with 
chronic  Bright' s  disease  and  acute  peritonitis,  and  in  inanition.  It  is 
usually  an  accompanying  phenomenon,  also,  of  the  form  of  arhyth- 
mia,  described  before,  known  as  the  trembling  or  delirious  pulse 
(pulsus  tremulii*). 

The  size  of  the  pulse-wave  has  no  necessary  relation  to  the  force 
or  intravascular  pressure.  A  strong  pulse  is  not  necessarily  a  large 
one,  as  the  arteries  may  be  contracted  and  resistant;  nor  is  a  weak 
pulse  necessarily  a  small  one,  as  a  full,  large  pulse  may  be  associated 
with  marked  feebleness  of  cardiovascular  tone. 

(iii)  Tension. — By  this  term  is  meant  the  feeling  of  pressure 
communicated  to  the  fingers  by  the  blood  through  the  arterial  walls. 
It  includes  the  estimation  of  the  pressure  between  the  beats  as  well 
as  the  pulsations  themselves — that  is,  the  diastolic  as  well  as  the 
maximum  or  systolic  pressures  (corresponding  to  the  systole  and  dias- 
tole of  the  arteries,  respectively).  Practically,  this  character  of  the 
pulse  is  observed  in  the  same  manner  as  th-a  force  of  the  heart  action 
is  judged — by  noting  the  degree  of  compressibility.  Therefore,  we 
speak  of  two  deviations  from  the  normal  tension  or  tightness  due 
to  intravascular  pressure:  the  hard  pulse  (pulsus  durus)  and  the 
soft  pulse  (pulsus  mollis). 

In  estimating  the  tension,  care  must  be  exercised  in  discriminating 
it  from  either  the  sclerotic  hardening  of  the  arterial  walls,  on  the 
one  hand,  or  the  fatty  atheromatous  softening,  on  the  other;  the 
arterial  walls  must  be  considered  apart  from  the  actual  blood  pressure 
from  within,  and  its  independent  effects  upon  them.  Considerable 
practise  is  necessary  before  skill  is  attained  in  properly  and  efficiently 
gaging  the  pulse-tension.  For,  although  instrumental  aids  are  avail- 
able for  scientific  and,  occasionally,  hospital  work,  in  99  out  of  100 
cases  the  fingers  must  remain  the  most  convenient,  sentient,  and 
practically  trustworthy  agents. 

Instruments. — Right  here,  the  apparatus  used  as  diagnostic  aids 
in  studying  the  blood  pressure  may  be  referred  to  briefly,  the  student 
obtaining  further  information  and  details  in  works  on  physiology 
and  general  medical  diagnosis. 

The  Sphygmomanometer. — Blood  pressure  instruments  have  been 
constructed  along  two  different  lines:  one  aiming  to  eliminate  the 
subjective  factor  by  a  simple  instrument  accurately  and  graphically 
recording  the  blood  pressure,  the  other  to  obtain  the  systolic  or  maxi- 


326 


PHYSICAL    DIAGNOSIS 


mum  blood  pressure  simply  by  exerting  sufficient  instrumental  pres- 
sure to  obliterate  the  distal  pulsations.  In  tbe  latter  method,  v.  Basch 
invented  the  first  instrument  of  any  value,  although  not  scientifically 
accurate,  and  yet  useful,  perhaps,  in  aiding  along  lines  of  indications 
and  results  of  treatment  (C.  E.  Brush,  Johns  Hopkins).  The  former 
method  is  exemplified  in  the  instrument  of  Roy  and  Adami,  in  1890. 


FIG.  68. — STANTON'S  SPHYGMOMANOMETER. 
(Cut  from  The  Arthur  H.  Thomas  Co.) 

Of  the  v.  Basch  type,  the  most  commonly  used  sphygmomanometer 
is  the  Riva-Rocci.  It  consists  in  the  application  to  the  middle  of  the 
upper  arm  of  a  cuff  like  a  pneumatic  tire,  about  12  cm.  wide  (as 
improved).  This  is  connected  with  a  mercury  manometer  by  a  piece 
of  rubber  tubing,  to  which  is  also  joined  similarly  a  rubber  hand 
bulb,  thus  forming  a  closed  system.  "  The  pressure  is  raised  by 
compressing  the  bulb  until  the  radial  pulse  can  no  longer  be  felt, 
when  the  height  of  the  column  of  mercury  in  the  manometer  will 
represent  the  pressure  necessary  to  overcome  the  pressure  of  the  blood 
in  the  artery,  or,  in  other  words,  the  blood  pressure"  (Musser). 

By  the  methods  of  Erlanger  and  Strassburger,  more  scientific  and 
satisfactory  results  may  be  obtained,  in  that  both  the  systolic  and 
diastolic  pressures  are  graphically  recorded.  The  cumbersomeness  and 
expensiveness  of  these  instruments  are  the  principal  objections  to  their 
use  by  the  general  practitioner. 

Gaertner's  tonometer  is  another  variety  of  apparatus  for  estimat- 


EXAMINATION    OF    THE    BLOOD-VESSELS         327 

ing  the  sustained  pressure  within  the  arteries.  Although  more  con- 
venient to  use,  it  is  inaccurate,  because  dependent  upon  too  many 
inadvertencies  of  technic,  and  the  uncertainties  of  the  subjective  cri- 
terions  of  both  patient  and  physician.  In  any  event,  both  systolic 
and  diastolic  pressures  should  be  taken,  the  difference  between  the 
two  representing  the  real  blood  pressure. 

The  Normal  Blood  Pressure. — This  varies  according  to  the  influ- 
ence of  a  number  of  physiologic  factors,  such  as  bodily  position,  age, 
sex,  rest,  exercise,  excitement,  the  taking  of  food,  the  time  of  day, 
etc.  The  tension  is  higher  in  the  erect  than  the  sitting  position,  and 
in  the  sitting  than  in  the  decubital  position.  Gennari  found,  how- 
ever, that  immediately  after  rising  from  a  reclining  posture,  in  health, 
there  was  a  slight  drop  in  the  blood  pressure.  In  fatigued  and  tem- 
porarily debilitated  conditions,  this  fall  of  pressure  on  rising  is  still 
more  noticeable,  being  marked  just  before  syncope.  The  tension  in 
adults  is  greater  than  in  children,  and  still  more  marked  in  the  aged. 
It  is  usually  a  trifle  less  in  women  than  in  men,  greater  after  physical, 
mental,  social,  and  emotional  exertion  and  excitement,  a  full  meal,  and 
during  the  most  strenuous  working  hours  of  the  day.  Generally,  the 
average  normal  blood  pressure  may  be  stated  as  about  120  mm.  of 
mercury  in  the  manometer.  Below  110  mm.  and  above  160  mm.  Hg 
are  considered  abnormal  pressures,  the  comparison  being  made  with 
the  subject  at  rest. 

Or  Strassburger's  "  blood-pressure  quotient "  may  be  adopted  to 
express  the  condition.  This  is  obtained  by  dividing  the  blood  pressure 
— the  difference  between  the  systolic  and  diastolic  pressure — by  the 
systolic  pressure.  Normally,  this  averages  0.25,  and  its  variations 
aid  in  determining  whether  the  changes  are  due  to  stronger  or  weaker 
ventricular  contractions,  or  to  increased  or  decreased  peripheral 
resistance. 

Pathologic  Blood  Pressures. — The  high-tension  or  hard  pulse 
occurs  when  one  or  both  of  the  two  principal  factors  are  operating — 
increased  peripheral  resistance,  especially,  and  increased  cardiac  force. 
The  pressure  of  a  large  volume  of  blood,  as  in  plethora,  must  also 
be  considered  in  many  cases.  Whatever  the  singleness  or  combination 
of  these  causative  conditions,  the  pressure  is  at  its  maximum  during 
the  cardiac  systole.  Nevertheless,  it  is  the  pressure  or  tension  of  the 
pulse  between  the  beats,  the  prolonged  and  sustained  blood  pressure 
and  hard  pulse,  which  is  of  most  value  in  diagnosis.  For  there  may 
be  a  high-tension  pulse  which  is  accompanied  by  a  low  pressure  be- 
tween the  beats,  as  in  aortic  insufficiency,  thus  indicating  strong 


328 


PHYSICAL    DIAGNOSIS 


cardiac  action,  but  not  increased  peripheral  resistance.  Indeed,  the 
discovery  of  a  high-tension  pulse  is  of  direct  importance  in  the  diag- 
nosis of  the  latter  condition  as  its  chief  cause. 


FIG.  69. — JANEWAY'S  SPHYGMOMANOMETER. 

High  blood-pressure  pulse  is  characteristic  in  chronic  Bright's 
disease  and  arteriosclerosis  with  contracted  kidney;  in  gout  and 
chronic  autotoxemia  leading  to  arterial  atheroma;  in  chronic  lead- 
poisoning;  in  cerebral  hemorrhage  (often  very  high);  diabetes  in 


EXAMINATION    OF    THE    BLOOD-VESSELS          329 

elderly,  gouty  persons;  chronic  emphysema;  angina  pectoris;  hyper- 
trophy of  the  left  ventricle. 

A  high-tension  pulse  is  at  the  same  time  frequently  a  small  pulse, 
and  one  in  which  the  wave  is  of  long  duration,  comparatively,  in 
passing  under  the  palpating  finger.  As  the  great  value  of  diagnosti- 
cating hypertension  in  the  arteries  hinges  upon  its  application  to 
prognosis,  prophylaxis,  and  treatment,  practise  in  detecting  it  in  its 
incipiency  is  a  sine  qua  non  if  the  permanent,  incurable  thickenings 
of  the  arterial  walls  are  to  be  anticipated  and  avoided. 

The  low-tension  or  soft  pulse  requires  but  slight  pressure  from 
without  to  obliterate  it.  It  feels  as  collapsible  as  if  the  artery  were 
filled  with  gas.  Because  of  the  relaxed,  non-resistant  state  of  the 
vascular  walls,  the  pulse-waves  are  usually  high  from  free  expansion 
with  each  ventricular  systole.  But  if  the  heart  is  simultaneously  weak 
and  the  dynamic  quantity  of  blood  in  the  arteries  small,  the  latter 
may  seem  small  and  contracted,  and  yet  manifest  a  low-tension  or 
"  running  "  or  "  gaseous  "  pulse,  so  that  the  artery  between  the  beats 
becomes  practically  impalpable. 

Dicrotism  is  a  characteristic  feature  of  the  soft,  compressible 
pulse,  wherein  the  main,  distinct  wave  is  immediately  followed  by  a 
slight  secondary  recoil  wave.  This  is  a  common  sign  in  typhoid 
fever,  some  cases  of  neurasthenia,  anemia,  and  other  forms  of  marked 
debility,  and  in  aortic  regurgitation,  owing  to  the  sudden  fall  of 
blood  pressure  as  soon  as  the  ventricular  contraction  ceases.  The 
dicrotic  pulse  may  not  be  detected  in  extreme  rapidity  of  the  heart 
action. 

The  pulse  of  low  tension  may  be  an  accompaniment  of  many  of 
the  cardiac  affections  where  myocardial  incompetency  ensues.  It  may 
be  found  in  some  persons  in  hot  weather,  and  in  others  as  a  hereditary 
peculiarity.  Gennari's  experience  leads  him  to  believe  that  the  fact 
that  as  in  heart-disease  the  blood  pressure  varies  very  little  with  the 
patient's  change  of  position,  neuroses  of  this  organ  may  be  differen- 
tiated, because  in  his  cases  the  pressure  became  much  reduced  when 
the  patient  sat  up,  and  the  pulse  dicrotic. 

Pulsus  Pamdoxus. — This  is  a  variety  of  abnormal  pulse  in  which 
the  tension  and  other  qualities  are  conversely  affected  by  the  respira- 
tory function.  Instead  of  the  pulse  tension  being  heightened  by  in- 
spiration, as  in  the  normal,  in  the  paradoxical  pulse  the  tension  is 
low  at  the  end  of  inspiration,  and  likewise  high  at  the  end  of  expira- 
tion instead  of  low  in  the  normal  at  this  period.  At  the  same  time, 
a  converse  relation  of  the  volume  of  the  pulse  to  the  respiration  is 


330  PHYSICAL    DIAGNOSIS 

observed;  that  is,  the  pulsus  paradoxus  is  character ize< I  by  decreased 
volume  during  inspiration,  and  increased  during  expiration;  indeed, 
during  a  full  and  deep  inspiration  the  pulse  may  be  so  small  as  to  be 
hardly  felt  at  all.  This  pulse  is  usually  the  result  of  some  mechanical 
obstacle  (pulmonary  traction?)  to  the  emptying  of  the  left  ventricle 
into  the  aorta  during  the  inspiratory  act.  As  such  it  is  an  important 
sign  of  mediastinal  pericarditis  with  fibroid  adhesions,  in  which  the 
cords  or  bands  pass  from  the  sternal  region  in  such  a  manner  as  to 
bend  and  constrict  the  great  vessels  near  their  roots  when  put  upon 
the  stretch  by  the  inspiratory  dilation  of  the  thorax ;  venous  engorge- 
ment and  reduplicated  second  sound  are  usually  associated. 

Secondly,  the  pulsus  paradoxus  may  be  caused  by  a  condition 
which  increases  the  negative  inspiratory  pressure  "  from  changes  which 
prevent  the  free  entrance  of  air  into  the  lungs."  Thus,  it  has  been 
noted  in  stenosis  of  the  larger  air- passages,  and  is  the  more  marked 
as  there  is  accompanying  feebleness  of  contractile  heart  power.  It 
may  also  occur  in  simple  pericardial  effusion,  adhesive  pericarditis, 
and  in  some  instances  of  large  pleural  effusion. 

As  systolic  retraction  of  the  lower  part  of  the  precordium  may 
accompany  adherent  pericardium,  and  as  the  degree  of  this  sign  de- 
pends largely  upon  the  strength  of  the  heart,  we  usually  have  an 
index  of  the  latter  in  the  relative  prominence  of  the  systolic  retraction 
and  the  paradoxical  pulse,  in  inverse  proportion;  that  is,  the  more 
marked  the  systolic  retraction  (and  hence  the  stronger  the  heart) 
the  less  marked  the  pulsus  paradoxus. 

(iv)  The  shape  of  the  pulse-wave  may  be  judged  by  the  palpating 
finger ;  thus,  whether  it  be  short  and  sharp,  or  quick  in  the  sense  that 
each  individual  wave  contact  has  a  brief  duration,  a  sudden,  quick 
rise  and  fall,  or  whether  the  wave  has  a  slow,  gradual,  prolonged 
rise  and  fall.  The  latter,  or  slow  pulse,  is  the  pulsus  tardus;  the 
former — quick  pulse — the  pulsus  celer.  Again,  to  avoid  misunder- 
standing and  confusion,  these  accepted  terms  are  to  be  distinguished 
from  those  indicating  an  exaggerated  or  diminished  number  of  pulse 
beats  per  unit  of  time,  namely,  the  terms  frequent,  infrequent,  rapid, 
and  so  on;  whereas  here,  quick  and  slow  pertain  exclusively  to  the 
duration  and  character  of  impact  of  the  individual  waves,  and  their 
manner  of  ascent  and  descent. 

Sphygmography. — For  purposes  of  accuracy,  study,  recording,  and 
reference,  the  form  and  succession  of  the  pulsations  may  be  repre- 
sented graphically  by  means  of  an  instrument — the  sphygmograph — 
well  known  to  students  in  the  physiologic  laboratory.  The  sphygmo- 


EXAMINATION    OF   THE    BLOOD-VESSELS         331 

graph  records  not  only  the  shape  of  the  pulse-curve  for  comparison 
with  other  tracings  and  with  the  palpatory  signs,  but  affords  an  idea 
of  other  elements.  It  gives  a  clear  exhibition  of  the  arhythmic 
pulse,  and  of  inequalities  of  volume,  force,  and  tension.  It  depicts 
smaller  waves  or  oscillations  that  ordinarily  are  too  fine  to  be  notice- 
able to  the  palpating  finger,  although  it  is  true  that  these  may  have 
little  or  no  decided  diagnostic  value.  Doubtless,  however,  were  sphyg- 
mographic  tracings  taken  oftener,  and  studied  generally  with  the 
assiduity  given  in  the  interpretation  of  Rontgenograms,  the  skill  thus 
developed  might  find  graphic  meanings  of  accuracy  and  larger  use- 
fulness. 

There  are  almost  as  many  forms  of  the  sphygmograph  as  of  the 
stethoscope,  but  the  ones  in  common  use  are  practically  improvements 
upon  that  devised  by  Marey,  such  as  Landois's,  Sommerbrodt's, 
Mahomed's,  Eichardson's,  Dudgeon's,  the  last  named  being  one  of 
the  best.  Although  of  but  limited  and  merely  supplemental  value 
in  actual  diagnosis,  the  sphygmograph  is  so  well  known  to  the  average 
student  and  physician  that  a  description  of  the  mechanism  and  the 
technic  of  its  application  is  omitted  here,  attention  being  directed 
merely  to  the  understanding  and  significance  of  the  tracings. 

Normal  Pulse  Tracing. — The  interpretation  of  the  normal  sphyg- 
mogram  is  comparatively  easy  when  one  notices  that  there  are  but 
two  main  trends  to  the  curve  representing  each  individual  pulse- 
wave,  namely,  the  sudden,  nearly  vertical,  uninterrupted  stroke  of 
ascent,  indicating  the  rise  of  pressure,  and  the  gradual,  oblique,  un- 
dulating stroke  of  descent — the  line  of  falling  pressure.  The  former 


FIG.  70. — TRACING  FROM  THE  PULSE  OF  A  NORMAL  MAN.     Pressure,  2£  oz. 
(Gibson  and  Russell.) 

line  is  known  as  the  percussion-wave,  and  ends  at  the  apex  curve. 
It  corresponds  to  the  sudden  distending  wave  of  blood  pressure  set 
up  by  the  left  ventricular  contraction  which  drives  the  blood  into 
the  aorta.  The  descending  limb  represents  a  quick  initial  fall  of 
pressure,  exaggerated  somewhat  by  the  fall  of  the  recording  lever  of 


332  PHYSICAL    DIAGNOSIS 

the  instrument,  which  has  him  thrown  too  high  by  the  distending 
impulse,  followed  by  the  predicrotic  or  tidal  wart',  which  is  believed 
to  be  caused  by  the  fullest  flow  of  blood,  or,  as  by  Roy  and  Adami, 
the  completion  of  the  intraventricular  pressure  ("  outflow- remainder 
wave").  A  second  wave  of  interruption  in  the  descending  limb  then 
follows,  known  as  the  dicroiic  or  recoil  wave.  This  represents  the 
reflected  wave,  probably  from  the  periphery,  due  to  the  sudden  check- 
ing of  the  column  of  blood  against  the  aortic  valve  and  the  slight 
increase  of  pressure  in  the  elastic  arterial  tube  at  the  moment  of 
oscillation.  Occasional  very  slight  oscillation  waves  may  be  noticed 
below  the  dicrotic  wave,  according  to  the  degree  of  elasticity  of  the 
radial  walls.  It  will  be  observed  that  in  the  normal  tracing  the  apex 
is  moderately  acute,  the  tidal  wave  very  small,  and  the  dicrotic  wave 
distinctly  marked. 

Pathologic  Pulse  Tracings. — A  comparative  study  of  the  abnor- 
malities of  sphygmograms  is  readily  made  by  noting  the  deviations 
from  the  normal  in  the  details  of  the  curve,  taken  in  systematic  order. 
It  is  here  that  the  shape  or  form  of  the  pulse-wave,  as  delineated  by 
the  sphygmograph,  serves  as  a  diagnostic  aid  to  palpation. 

We  consider,  therefore,  the  meaning  of  variations  of  the  percus- 
sion-wave or  upstroke,  its  height  and  obliquity;  the  breadth  or  acute- 
ness  of  the  apex;  the  prominence  or  absence  of  the  predicrotic  and 
dicrotic  waves;  the  general  character  of  the  descending  line,  and  the 
regularity  of  the  base  line. 

a.  The  Upstroke. — Increased  height  indicates  large  volume,  low 
tension,  and  a  sharp  systolic  contraction  of  the  heart;  hence  it  occurs 
in  aortic  regurgitation  (pulsus  celer],  and  in  the  early  stages  of 
febrile  states,  where  the  arterioles  are  considerably  relaxed. 

A  short  upstroke  points  to  slowness  rather  than  suddenness  of 
systole,  heightened  tension,  and  diminished  amplitude  of  pulse-wave, 
and  thus  is  found  in  such  conditions  as  aortic  stenosis,  contracted 
kidney,  gout,  mitral  regurgitation  (moderate  tension). 

Obliquity  of  the  ascending  or  anacrotic  limb  is  practically  nil  in 
the  normal  sphygmogram.  A  marked  sloping  backward  may  be  due 
simply  to  a  weak  ventricle,  or  may  signify  aortic  obstruction,  aneu- 
rism, or  to  a  thick  layer  of  subcutaneous  fat  over  the  radial  artery. 

On  the  other  hand,  when  the  tracing  shows  an  actual  bending 
forward  of  the  line  of  ascent,  it  means  a  quick  systole,  whereby  a 
large  volume  of  blood  is  shot  into  the  aorta  suddenly,  with  low  ten- 
sion, and  either  a  strong  or  weak  heart.  This  is  observed  again  in 
aortic  incompetency. 


EXAMINATION    OF    THE    BLOOD-VESSELS         333 

b.  The  Apex. — Increased  breadth  of  the  top  of  the  percussion- 
wave  indicates  a  slow,  forcible  filling  of  the  artery;  a  strong,  hyper- 
trophied  heart  laboriously   contending  against   increased  peripheral 
resistance   or   aortic  obstruction,   or    aneurism,    arteriosclerosis,   etc. 
Consequently  the  tension  is  also  usually  prolonged. 

Acuteness  of  the  apex  goes  with  the  signs  of  a  soft  peripheral 
circulation  (low  tension)  and  quick  initiative  of  ventricular  contrac- 
tion; therefore,  with  high  and  vertical  ascending  line,  as  in  aortic 
insufficiency. 

c.  The  Tidal  and  Dicrotic  Waves. — A  marked  tidal  wave  (pulsus 
lisfcriens)  points  to  the  conditions  of  high  tension — hypertrophied 
heart,  and  aortic  stenosis  or  thickened  arteries.     At  the  same  time 
the  apex  of  the  tracing  is  low  and  blunt. 

^niall  or  absent  predicrotic  wave  indicates  a  weak  heart,  or  a 
moderate  or  low-tension  pulse  with  a  heart  of  fair  or  good  strength, 
as  in  mitral  insufficiency. 

A  marked  dicrotic  wave  is  usually,  although  not  always,  a  sign 
of  low-tension  pulse  with  strong  heart.  When  the  notch  preceding  the 
wave  of  recoil  reaches  the  base  line  it  is  said  to  be  fully  dicrotic; 
when  it  falls  below  this  line  it  is  hyperdicrotic.  Dicrotism  is  likely 
to  be  marked  in  the  later  stages  of  depressing  fevers,  in  tuberculosis, 
and  the  like. 

Diminished  or  suppressed  dicrotic  wave  signifies  persistent  high 
(prolonged)  tension  and  forcible  left  ventricle,  preventing  the  recoil. 
It  may  be  a  negative  feature  of  the  sphygmogram  of  aortic  regurgi- 
tation,  because  the  aortic  check  to  the  column  of  blood  at  the  begin- 
ning of  cardiac  diastole  is  more  or  less  removed. 

d.  The  Descending  Line. — There  may  be  a  general  obliteration 
of  the  normal  characteristics  of  this  line,  the  slope,  length,  waves, 
and  notches  being  totally  altered,  and  irregular  throughout.     One 
finds   these  changes  frequently  in  the  sphygmographic  tracings   of 
aortic  and  mitral  stenosis,  in  the  later  stages  of  mitral  regurgitation, 
and  in  atheromatous  thickening  of  the  arteries. 

e.  The  Base  Line. — This,  itself,  may  manifest  irregularities  and 
undulations,   especially   where   cardiac   disease  is  accompanied  with 
marked  dyspnea  or  Cheyne- Stokes  breathing.     Thus  it  may  be  seen 
in  mitral  obstruction,  in  chronic  Bright's  disease  with  dilated  heart, 
in  tuberculous  meningitis  and  pericarditis,  and  in  certain  instances 
of  marked  dicrotism. 

(v)  Inequality  of  the  pulse-waves  (pulsus  inequalis)  or  irregu- 
larity exclusive  of  the  element  of  time  simply  refers  to  a  complexus 


APEX   OR  SUMMIT 


DIAGRAMMATIC 
SPHYGMOGRAM 

OF  THE 
NORMAL  PULSE 


PREDICROTIC    OR 
TIDAL   WAVE 


UPSTROKE 
PERCUSSION 

STROKE 
ASCENDING 

OR 

ANACROTIC 
LIMB 


DICROTIC    OR 
RECOIL   WAVE 


AORTIC   CLOSURE 


VENTRIC.  SYSTOLE 


AORTIC    INCOMPETENCY 
UPSTROKE  VERTICAL  AND  HIGH.      POINTED 
APEX.       ABRUPT     DESCENT.       DICROTIC 
WAVE  ALMOST  NIL. 


PULSUS    BISFERIENS 
TIDAL  WAVE  MARKED  AND  HIGH.     DICROTIC 
WAVE  ALSO  PRESENT. 


PULSUS     ALTERNAN8.          BEATS      OCCUR      IN 
PAIRS,    EVERY    SECOND    BEAT    SMALL. 


IRREGULARITY 

BlQEMINAL    PULSE.       BEATS     IN    GROUPS    OF 


IRREGULARITY 

MITRAL  INCOMPETENCY. 


IRREGULARITY 
MITRAL  STENOSIS. 


UNDULATING    BASE    LINE 
TUBERCULOUS  MENINGITIS. 


FIG.  71. — SPHYGMOGRAMS,  DIAGRAMMATIC  AND  ACTUAL.     (Butler.) 
334 


LOW    TENSION 

TIDAL  WAVE  ABSENT. 
DICROTIC  WAVE 
PROMINENT. 


FULLY  DICROTIC 


HYPERDICROTIC 


HIGH    TENSION 

TIDAL  WAVE  PROMINENT.      DICROTIC  WAVE 
INDISTINCT.     SUMMIT  BROAD. 


SENILE    PULSE   (ARTERIOSCLEROSIS) 
BLUNT  SUMMIT.     NUMEROUS  MINOR  WAVES. 


AORTIC   STENOSIS 

OBLIQUE  ASCENT.     BLUNT  SUMMIT.     SLOW 
DESCENT.    SECONDARY  WAVES  INDISTINCT. 


ANEURISM    IN   COURSE    OF    VESSEL 

SLOW    ASCENT    AND    DESCENT.       SECONDARY 
WAVES    INDISTINCT. 


NORMAL    TRACES 

MADE  BY  DUDGEON'S  SPHYG. 


MAREY'8   8PHYG. 


SOMMERBRODT'S    SPHYG. 


FIG.  72. — SPHYGMOGRAMS,  ACTUAL.     (Butler.) 


335 


336  PHYSICAL    DIAGNOSIS 

of  abnormalities  of  several  or  all  of  the  quality  characteristics  de- 
scribed. Not  only  the  frequency  of  the  pulse-heats  may  be  irregular, 
but  their  tension,  force,  size,  and  duration.  Indeed,  such  inequalities 
are  of  graver  significance  in  connection  with  weak  heart  than  mere 
arhythmia,  although  general  irregularity  without  serious  degenera- 
tion of  the  heart  may  exist  to  a  degree,  in  some  cases,  of  mitral  steno- 
sis. The  alternating  and  bigeminal  pulses,  and  the  inter cidens,  are 
forms  of  the  pulsus  inequalis. 

(d)  Symmetry. — In  the  healthy  individual,  corresponding  arteries, 
such  as  the  two  radials,  cervicals,  femorals,  give  rise  to  pulse-waves 
of  like  times  and  symmetric  qualities.  Hence,  in  order  to  determine 
the  presence  of  local  interferences  with  the  arterial  circulation,  the 
pulse  should  be  studied  comparatively  of  the  different  arteries  in 
the  same  person. 

The  principal  unilateral  abnormality  is  a  delay  of  the  pulse  on 
the  affected  side;  that  is,  on  the  side  which  thus  indicates  some  local 
obstacle  to  the  current  of  blood.  To  palpate  both  radials,  for  ex- 
ample, and  discover  an  asymmetry  of  pulse-impact  requires  some 
psychomotor  training  and  skill,  which  may  easily  be  acquired  by  prac- 
tise, however,  as  in  noting  the  difference  in  the  times  elapsing  be- 
tween the  carotid  and  radial,  or  the  carotid  and  dorsalis  pedis  pulses 
in  the  healthy  individual.  Besides  the  delay,  there  is  usually  at  the 
same  time  some  weakening  and  diminution  of  the  size  of  the  pulsa- 
tions, as  compared  with  the  unaffected  artery  on  the  opposite  side. 
In  some  cases  the  pulse  on  one  side  may  be  quite  obliterated. 

In  aneurism  of  the  aortic  arch  there  may  be  a  marked  interval 
between  the  time  when  the  pulse-wave  reaches  the  unobstructed  and 
the  obstructed  radial.  Other  causes  of  asymmetric  pulse  are,  tumors 
of  the  chest  cavity,  particularly  near  the  axilla;  thrombosis  and  em- 
bolism; in  pleuritic  exudations  of  large  size,  and  pneumothorax ;  in 
surgical  conditions  of  the  forearm,  and  abnormal  or  anomalous  dis- 
tributions of  the  arteries. 

Thus  a  delayed,  weak,  and  small  pulse  in  the  right  radial  indi- 
cates aneurism  of  the  ascending  aorta  or  innominate  artery,  or  of  the 
presence  on  the  right  side  of  any  of  the  preceding  disorders  men- 
tioned; on  the  left  side,  aneurism  of  the  descending  aorta,  especially 
near  the  junction  with  the  transverse  portion  of  the  arch,  and  similar 
lesions,  cicatricial  contractions,  etc.,  on  that  side. 

Likewise,  abnormality  of  the  pulse  in  one  or  other  femoral  or 
posterior  tibial  artery  may  point  to  thrombus  or  embolus,  or  tumor  or 
aneurism  affecting  the  abdominal  aorta. 


EXAMINATION    OF    THE    BLOOD-VESSELS          337 

Tortuosity  of  the  Aorta. — As  an  evidence  of  atheromatous  degen- 
eration, not  infrequently  a  premature  peculiarity,  one  may  detect 
through  relaxed  abdominal  walls,  as  in  women,  a  more  or  less  ser- 
pentine course  of  the  aorta  between  the  epigastrium  and  the  umbili- 
cus. At  the  same  time  the  aortic  walls  feel  stiffened  and  resistant 
to  pressure,  and  the  vessel  may  be  pushed  from  side  to  side  over  the 
spinal  column,  as  if  it  were  a  rubber  tube.  I  observed  this  most 
recently  in  a  married  woman  of  thirty-four  years,  who  had  given 
birth  to  one  child,  has  myopic  astigmatism,  and  no  evidence  of  vas- 
cular thickening  elsewhere.  This  condition  has  been  well  studied  in 
Rontgenography  by  Sailer  and  Pfahler. 

AUSCULTATION 

Normal  Arterial  Sounds  and  Murmurs. — The  arteries  which  may 
be  auscultated  are,  besides  the  aorta  and  the  pulmonary  artery,  the 
carotid,  subclavian,  brachial,  femoral,  and  rarely  the  popliteal  and 
posterior  tibial,  although  it  is  customary  to  examine  the  first  two 
only  in  most  instances. 

If  one  applies  the  binaural  stethoscope  very  lightly  over,  say,  the 
right  carotid  artery,  with  the  head  slightly  extended,  one  may  hear 
two  normal  sounds,  corresponding  with  the  cardiac  systole  and  dias- 
tole, and  synchronous  with  the  expansion  and  contraction  of  the  artery. 
The  first  sound  is  weaker  and  duller,  the  second  stronger  and  clearer. 
The  former  is  probably  partly  the  transmitted  first  cardiac  or  aortic 
sound,  and  partly  produced  independently  in  the  carotid  itself  by  the 
sudden  stretching  of  its  walls.  The  second  sound  is  simply  the  trans- 
mitted aortic  second  sound.  Not  infrequently  the  first  arterial 
sound  is  entirely  wanting,  especially  over  more  remote  arteries,  where 
the  transmissions  are  too  weak  to  be  heard.  A  systolic  sound  may  be 
audible  in  many  normal  individuals  along  the  course  of  the  abdominal 
aorta,  but  here  the  second  sound  is  usually  inaudible. 

If  the  stethoscope  is  pressed  upon  the  artery  with  sufficient  firm- 
ness, an  induced  or  pressure  murmur  is  generated.  This  may  be 
heard  over  other  large  arteries  that  are  so  situated  anatomically  as 
to  be  thus  compressible.  The  murmur  is  systolic,  and  has  a  rushing 
quality  of  sound  which  is  increased  in  intensity  as  the  stethoscopic 
pressure  is  increased  to  the  point  of  obliterating  the  normal  systolic 
arterial  sound.  There  is  no  diastolic  pressure  murmur  because  there 
is  not  sufficient  backward  movement  of  the  blood  to  create  frictional 

disturbances  and  vortices. 
24 


338  PHYSICAL    DIAGNOSIS 

Abnormal  Arterial  Sounds  and  Murmurs. — A  harsh  systolic  mur- 
mur replacing  the  conducted  first  sound  is  heard  over  the  carotid  in 
aortic  stenosis.  On  the  other  hand,  in  aortic  re  gurgitation  the  second 
sound  of  the  carotid  and  subclavian  is  wanting,  and  the  diastolic 
murmur  is  faintly  heard,  if  at  all.  Furthermore,  in  these  arteries 
not  only,  but  in  some  cases  in  the  brachial,  femoral,  and  even  in  the 
radial  and  ulnar,  and  the  peroneal  and  dorsalis  pedis  arteries,  single 
systolic  sounds  may  be  audible  with  the  lightest  pressure  of  the  stetho- 
scope. Again,  with  considerable  pressure,  a  double  murmur  (Duro- 
ziez's)  is  heard  over  the  femoral  artery  in  certain  cases  of  aortic 
insufficiency.  The  single  sounds  are  probably  produced  by  the  sudden 
and  abnormally  forcibly  tense  filling  of  the  arteries  by  the  huge, 
hypertrophied  heart,  at  a  time  when  they  are  abnormally  relaxed 
because  of  centripetal  as  well  as  centrifugal  emptying. 

A  double  sound  as  well  as  double  murmur  may  be  heard  over 
the  crural  artery  in  some  cases  of  aortic  regurgitation,  of  mitral 
stenosis,  in  lead-poisoning,  and  in  pregnancy  (Gerhardt).  The  sec- 
ond sound  is  caused  by  the  sudden  collapse  of  the  artery,  with  a 
large,  quick  pulse.  The  second  part  of  the  double-pressure  murmur 
of  Duroziez  is  attributed  to  the  short  reflux  of  blood  in  aortic  insuffi- 
ciency. These  embrace  the  principal  sounds  of  conduction  in  the 
arteries. 

MURMURS  DUE  TO  DISEASE  OF  THE  ARTERIAL  WALLS. — In  the 
aorta,  roughening  of  the  inner  coat  of  the  arch,  due  to  chronic  aortitis 
in  old  men,  may  produce  a  murmur  audible  over  the  carotids  and 
subclavians  by  transmission.  Or  it  may  be  caused  by  narrowing  of 
the  lumen  by  thick  calcareous  plates,  or  by  pressure  from  without, 
as  from  mediastinal  tumors,  enlarged  lymph  glands,  or  an  aneurismal 
sac.  Localized  cndartcritis  of  the  larger  arteries  may  also  be  sus- 
pected, as  where  a  soft  systolic  murmur  is  heard  over  a  portion  of 
the  crural  artery,  for  example;  or  the  double  murmur  of  pressure 
may,  when  heard  over  one  of  the  larger  arterial  trunks,  indicate  an 
endarteritis  or  tortuosity  there. 

MURMURS  DUE  TO  Low  TENSION. — In  cases  of  marked  relaxation 
of  the  vessels,  as  from  congenital  liypoplasia,  or  fatty  degeneration, 
or  chronic  disease,  the  arteries,  especially  the  innominate  and  carot- 
ids, show  increase  of  caliber,  but  soft  pulse,  and  on  auscultation  often 
reveal  soft  systolic  murmurs. 

ANEMIA  AND  CHLOROSIS. — These  conditions  of  altered  blood  com- 
position are  usually  accompanied  with  the  so-called 'anemic,  heinic, 
or  functional  arterial  murmurs.  They  are  also  systolic  in  time, 


EXAMINATION    OF    THE    BLOOD-VESSELS          339 

seldom  loud,  although  rarely  musical,  and  best  heard  over  the 
carotid. 

THE  SUBCLAVIAN  SYSTOLIC  MURMUR. — This  requires  separate  and 
special  consideration  from  what  references  have  already  been  made  to 
subclavian  phenomena.  ]t  is  a  fact  that  sometimes  in  health  a  short, 
systolic  whiffing  or  blowing  sound  may  be  heard  over  both  subclavian 
arteries,  usually  stronger  on  the  left  side  and  at  the  end  of  inspira- 
tion. It  is  best  heard  below  the  clavicle  at  its  outer  end.  When 
unilateral,  it  has  a  suspicious  pathologic  significance,  namely,  of  apical 
tuberculosis  with  pleuritic  adhesions,  the  latter  pulling  or  bending 
the  artery,  and  thus  constricting  its  lumen  during  the  act  of  inspira- 
tion. Even  when  of  bilateral  occurrence,  the  possibility  of  incipient 
disease,  or  of  previously  formed  pleuritic  exudation,  should  be  thought 
of;  also,  fibroid  phthisis  with  traction,  and  tumor  pressure. 

Murmurs  in  the  axillary  artery  may  be  due  to  pressure,  especially 
in  women  of  advanced  years,  by  cancerous  enlargement  of  the  lym- 
phatic glands;  in  early  life,  by  tuberculous  glands. 

Systolic  murmurs  may  be  quite  distinct,  even  loud,  over  the  goiter 
(thyroid  gland)  of  Basedow's  disease;  also  over  the  pregnant  uterus 
(uterine  souffle).  Both  of  these  are  of  arterial  origin. 

Finally,  may  be  mentioned  the  systolic  cerebral  blowing  or  hum- 
ming heard  really  normally  over  the  anterior  fontanelle  of  infants 
between  the  third  month  and  the  sixth  year.  This  may  be  audible 
also  over  the  carotids,  and  by  Jurasz  is  believed  to  be  the  carotid 
murmur  conducted  upward,  the  artery  being  subjected  to  compression 
during  the  development  of  the  skull. 

THE    CAPILLARIES 

The  capillaries  give  color  or  complexion,  redness  or  pallor  to  the 
skin  according  to  their  fulness.  The  only  abnormal  capillary  phe- 
nomenon of  diagnostic  importance  is  the  capillary  or  subungual  pulse. 
This  consists  of  an  alternate,  rhythmic  reddening  and  paling  of  the 
pink  zone  over  the  root  of  the  finger  nail,  corresponding  to  the  quick 
and  extreme  filling  and  emptying  of  the  capillaries,  and  associated 
with  the  large  and  quick  (celer)  pulse  of  aortic  insufficiency,  with 
hypertrophy  of  the  left  ventricle.  This  alternate  waxing  and  waning 
of  color,  synchronous  with  the  cardiac  action,  is  not,  however,  exclu- 
sively significant  of  aortic  regurgitation,  but  may  be  visible  in  several 
states  of  decreased  blood  pressure  and  low  arterial  tension.  This 
sign  may  be  elicited  similarly  by  drawing  out  the  lower  lip  and 


340  PHYSICAL    DIAGNOSIS 

placing  a  microscope  slide  against  the  mucous  membrane  so  as  to 
produce  a  slight  pallor,  which  will  change  to  a  faint  pinkish  tint 
with  each  systole  of  the  heart.  A  flush  streak  on  the  forehead,  caused 
by  sharply  drawing  the  ringer  across  it,  may  also  have  corroborative 
value  in  the  alternate  paling  simultaneous  with  cardiac  diastole. 


THE   VEINS 

As  with  the  arteries,  so  with  the  veins,  consideration  is  unavoid- 
able in  connection  with  cardiac  and,  to  a  lesser  degree,  pulmonary 
diseases.  The  phenomena  of  the  venous  circulation  have  diagnostic 
significance  as  related  to  cardiac  affections,  whether  they  occur  as 
general  venous  involvement  or  in  a  local  way.  Thus  we  find  general 
venous  distention  whenever  the  return  flow  of  venous  blood  as  a  whole 
is  hindered,  particularly  from  failing  right  ventricle,  the  result  of 
mitral  or  tricuspid  valve  defects,  or  of  relative  tricuspid  insufficiency 
because  of  interference  of  the  pulmonary  circulation  due  to  emphy- 
sema, chronic  asthma,  and  extensive  fibroid  phthisis.  Here  we  have 
associated  more  or  less  cyanosis  and  general  edema.  Local  venous 
distentions  and  abnormal  pulsations  will  be  considered  as  more  espe- 
cially within  the  scope  of  this  book,  as  found  on  the  thorax  and  neck. 
In  fact,  the  jugulars  are  the  most  conveniently  located  and  amply 
sized  of  all  the  veins  whereby  the  condition  of  the  right  heart  may 
be  estimated  fairly;  indeed,  it  may  be  said  that  the  signs  of  the 
jugular  veins  are  at  once  the  most  available  and  reliable  indices  of  the 
venous  circulation  in  general. 

INSPECTION 

The  pathologic  phenomena  observed  on  inspection  of  the  veins  arc : 

(1)  Engorgement,  and  therefore  enlargement,  of  the  superficial  veins; 

(2)  pulsations  or  undulations,  having  respiratory  or  cardiac  causation. 
Fulness  of  the  Veins. — In  health  the  prominence  of  the  cervical 

veins  depends  partly  upon  the  amount  of  subcutaneous  fat  and  partly 
upon  the  degree  of  physiologic  activity,  other  things  being  equal. 
Of  course,  the  position  of  the  head  and  the  depth  and  period  of  the 
respirations  are  also  influencing  factors.  Of  the  two  jugulars,  only  the 
external,  coursing  obliquely  over  the  sternocleidomastoid  muscle,  and 
the  right  better  than  the  left,  is  distinctly  visible ;  the  internal  jugu- 
lar, underneath  this  muscle,  and  its  bulbous  junction  with  the  sub- 
clavian  vein,  are  not  visible  in  health.  In  fat-necked  individuals, 


EXAMINATION    OF    THE    BLOOD-VESSELS         341 

even  the  external  vein  may  not  be  .seen,  notwithstanding  the  head  is 
placed  low  and  turned  toward  the  opposite  side  to  bring  it  out,  unless 
the  habit  or  physical  temperament  is  that  of  the  full-veined  plethoric. 
The  veins  show  better  in  men  than  in  women,  and  in  those  who  lead 
active,  energetic  lives.  Also,  they  are  fuller  during  such  acts  as 
coughing,  laughing,  running,  and  the  like. 

Abnormally  distended  jugulars  are  evidence  of  any  form  of  valvu- 
lar or  pulmonary  disease  causing  obstructed  circulation  through  the 
lungs,  and  consequently  tricuspid  regurgitation.  Or  they  may  be 
produced  by  aneurismal  or  neoplastic  (mediastinal)  compression  of 
the  superior  vena  cava  or  innominate  vein.  In  the  case  of  mediastinal 
tumor  there  may  be  suggestion  of  it  in  the  presence  over  the  sternum 
of  a  few  single  engorged  veins  of  small  size.  In  marked  cases  of 
engorgement  the  jugular  bulb  is  also  seen  swelling  out  $  to  ^  in. 
above  the  sternoclavicular  articulation  from  behind,  and  between  the 
divided  insertions  of  the  sternocleidomastoid  muscle. 

A  point  in  the  diagnosis  of  cervical  vein  engorgement,  as  differ- 
entiated from  a  merely  physiologic  or  plethoric  fulness,  may  be  aided 
by  noting  the  susceptibility  of  the  former  abnormal  condition  to  re- 
spiratory movement.  The  pathologic  turgidity  is  usually  distinctly 
lessened  during  inspiration  and  increased  during  expiration,  while 
normally  this  difference  of  undulatory  rise  and  fall  is  hardly  per- 
ceptible. 

Venous  Undulations  and  Pulsations.  (1)  THOSE  CAUSED  BY 
Iii-.siMUATOHY  MOVEMENTS. — formally,  the  continuous  flow  of  blood 
in  the  veins,  as  manifested  in  those  of  the  neck  while  collateral  atten- 
tion is  also  given  to  the  movements  of  forced  respiration,  shows  an 
unmistakable  filling  during  expiration,  and  a  relative  collapse  during 
inspiration,  because  of  the  negative  intrathoracic  pressure  at  that 
time  which  draws  the  blood  toward  the  heart,  the  swelling  of  the 
jugulars  during  expiration  being  due  to  the  positive  pressure  exerted 
upon  the  veins  then,  which  causes  "  a  retrograde  wave  of  blood  to 
close  the  valve  above  the  jugular  bulb." 

Pathologically,  an  aggravation  of  the  jugular  undulations  accom- 
panying the  movements  of  respiration  are  significant  of  chronic  asthma 
and  emphysema;  particularly  in  the  latter  disease,  where  the  swelling 
of  the  cervical  veins,  while  the  patient  is  lying  down,  is  a  conspicu- 
ous feature.  Coughing  increases  the  turgidity  of  the  undulations 
markedly.  In  the  rare  affection  of  fibrous  mediastinopericarditis,  a 
reversal  of  this  phenomenon  takes  place;  that  is,  the  jugular  veins 
are  filling  during  inspiration,  because  of  the  bending  of  the  superior 


342 


PHYSICAL    DIAGNOSIS 


vena  cava  by  adhesions  during  that  act,  thus  hindering  the  venous 
flow  in  the  direction  of  the  heart. 

(2)    THOSE  CAUSED  BY  CARDIAC   CONDITIONS. — In    licallli,  the 
venous  pulse  is  a  gentle  undulation,  best  seen  in  the  external  jugular 


LAI  SINUS 

THROMBOSIS  OF  * 

EMPTY JUGUL 

INHPETROSAL  SINUS 


INT.  JUGULAR. 
EXT.  JUG. 


VALVE 
JUG.  BULB. 
INNOMINATE  VEIN. 

PSUR  VENA  CAVA. 

PRESSURE  ON  THESE 
VESSELS  CAUSES  OVER 


5UBCLAV1AN  VEIN 


FULL  JUGULARS.) 

RT.AIMCLE 


TRIG  USPJD  VALVE 
iNSur.  causes 

SYSTOL.JUGULAn 
ULSATION. 


FIG.  73. — DIAGRAM  or  THE  RIGHT  EXTERNAL  AND  INTERNAL  JUGULARS,  SHOWING 
THE  MECHANISM  OF  JUGULAR  COLLAPSE,  DISTENTION,  AND  PULSATION.     (Butler.) 

vein  in  thin  persons.  The  wave  rises  and  passes  just  before  the 
cardiac  systole,  and  hence  (a)  the  normal  venous  pulse  is  presystolic 
orjnegative.  (6)  The  pathologic  modification  of  this  pulse  makes  it 


EXAMINATION    OF    THE    BLOOD-VESSELS          343 

systolic  in  time,  or  positive.  Obviously,  it  is  important  not  to  confuse 
the  systolic  venous  with  the  synchronous  carotid  pulse.  A  pulsating 
jugular  may  be  due  to  the  transmission  of  the  carotid  impulse.  Iff 

iso,  then  "  milking  "  the  vein  upward  will  not  be  followed  by  a  venous! 

Iwave  from   below,  as   is   the  case  with  a  positive  venous  pulse  of! 

nricuspid  regurgitation,  which  is  almost  always  the  cause  of  it. 

(rt)  The  normal  or  negative  venous  pulse,  as  seen  in  the  external 
jugular,  should  not,  as  one  author  writes,  be  designated  as  a  kind  of 
undulatory  collapse  of  the  vein  occurring  with  the  systole  of  the  heart, 
although  that  does  actually  happen.  For  the  complete  filling  of  the 
vein,  which  makes  it  rhythmically  visible  before  its  emptying,  is  pre- 
systolic,  and  hence  negative,  since  it  is  not  due  to  a  positive  or  systolic 
wave  of  blood  from  the  heart.  This  may  be  demonstrated  by  com- 
pressing the  vein  near  its  middle  with  the  finger,  whereupon  pulsation 
ceases  on  the  proximal  side,  showing  that  the  blood  does  not  regur- 
gitate from  the  heart;  and  at  the  same  time  there  is  a  decided  diminu- 
tion of  undulation  on  the  distal  side,  showing  that  the  pulsation  is 
not  transmitted  from  the  carotid.  In  observing  the  normal  jugular 
pulse,  it  is  characteristic  to  see  the  presystolic  wave  rise  slowly,  to 
be  followed  by  a  sudden  systolic  collapse,  then  a  short  but  appreciable 
interval  before  the  next  wave.  The  phenomenon  is  due  to  the  systole 
of  the  right  auricle ;  that  is,  since  the  auricle  contracts  during  venous 
distention — both  at  presy stole — the  back  current  caused  is  stopped 
at  the  jugular  valve,  which  transmits  the  shock  above.  The  negative 
venous  pulse  may  also  be  distinguished  from  carotid  pulsation  not 
only  by  the  time,  but  by  the  sensation  to  the  finger  of  undulation 
rather  than  circumscribed  impact,  by  the  "  impression  of  passive  force 
rather  than  of  active  power,"  and  by  the  greater  anatomic  extent 
of  wave. 

The  presystolic  venous  pulse  is  often  prominently  visible  in 
chlorosis. 

(b)  The  positive  or  pathologic  pulse,  synchronous  with  the  apex- 
beat  and  carotid  impulse,  is  best  seen  at  the  right  jugular  bulb,  in 
the  sternocleidomastoid  fossa.  Should  the  valve  here  in  the  internal 
jugular  become  incompetent,  the  systolic,  positive  venous  pulsation 
will  then  be  visible  upward  in  the  neck.  This  sign  is  pathognomonic 
of  tricuspid  regurgitation,  the  reflux  blood  current  being  urged  up- 
ward through  the  incompetent  orifice  into  the  auricle  with  each  con- 
traction of  the  right  ventricle.  Thence  it  passes  into  the  superior 
cava,  right  innominate,  and  internal  jugular  veins  to  the  bulbar  valve, 
which  soon  ceases  to  stand  the  strain,  and  itself  becomes  incompetent. 


344 


PHYSICAL    DIAGNOSIS 


The  jugular  pulse  may  be  absent  in  the  upright  posture,  as  gravity 
favors  its  appearance. 

Systolic  venous  pulse  may  appear  later  on  the  left  side  in  severe 
cases  of  tricuspid  regurgitation ;  and,  on  the  other  hand,  when  marked 


NORMAL 
PRESYSTOLIC 
PULSATIO 


AUR. 
SYST. 

VENTRICULAR 
SYSTOLE 

DIASTOLE 

FIG.  74. — DIAGRAM  SHOWING  THE  PRESYSTOLIC  AND  SYSTOLIC  JUGULAR  PULSE. 

(Butler.) 

enfeeblement  of  the  heart,  or  extreme  rapidity,  ensue,  the  pulsations 
may  quite  disappear. 

A  positive  centrifugal  venous  pulse  may  exist  temporarily  a*  the 
result  of  functional,  muscular,  tricuspid  insufficiency  connected  with 
pronounced  anemia.  This  often  appears  at  the  same  time  as  the 
soft  systolic  murmur  of  a  relative  mitral  insufficiency,  thus  differing 
from  the  tardily  appearing  tricuspid  insufficiency  secondarily  due  to 
an  organic  (endocarditic)  mitral  defect  (von  Leube). 


PALPATION 

Palpation  may  have  to  be  brought  to  the  aid  of  inspection  in 
some  cases  where  by  the  latter  method  alone  the  diagnosis  of  positive 
venous  pulsation  may  be  difficult,  doubtful,  or  impossible.  Thus,  it 
must  be  decided  first  that  the  pulsation  is  really  systolic,  and  then 
that  it  is  intravenous  in  origin,  and  not  transmitted  from  the  adjacent 
carotid.  The  former  may  be  determined,  of  course,  by  palpating  the 
apex-beat  and  noting  its  synchronism  with  the  jugular  pulse.  If, 
owing  to  rapidity  of  cardiac  action,  there  is  doubt  as  to  the  systolic 


EXAMINATION    OF    THE    BLOOD-VESSELS         345 

time  of  a  venous  pulsation,  the  finger  may  be  placed  upon  the  vein  at 
the  root  of  the  neck,  and  slid  upward  with  sufficient  pressure  to 
empty  it.  Immediate  filling  and  pulsating  would  indicate  incompe- 
tence of  the  jugular  and  tricuspid  valves,  whereas  competency  of  these 
valves  would  be  accompanied  with  a  distinctly  slower  refilling  of  the 
vein  from  its  small  collaterals.  The  phenomenon  is  also  less  likely 
to  be  altered  by  deep  respiratory  action  than  is  the  normal  or  nega- 
tive pulse. 

Transmitted  carotid  impulse  may  also  be  differentiated  from  true 
venous  pulsation  of  systolic  time  by  stroking  or  "  milking  "  the  vein 
from  below,  or  by  placing  the  finger  midway  between  the  clavicle 
and  ear,  which,  if  the  pulsation  is  imparted  or  false,  will  cause  a 
distention  of  the  vein  and  exaggeration  of  pulse  above,  and  a  corre- 
sponding emptiness  and  collapse  below.  But  if  the  pulsation  is  ac- 
tually in  the  vein,  from  a  tricuspid  insufficiency,  the  filling  will  be 
noticed  as  before. 

In  some  cases,  instead  of  a  single  venous  throb,  synchronous  with 
the  systole  of  the  heart,  there  may  be  a  double  wave,  the  presystolic 
being  weaker  than  the  systolic  wave. 

The  systolic  venous  pulse  may  be  simulated,  rarely,  by  a  sudden 
diastolic  collapse  of  the  jugulars  due  to  the  sudden  diastole  of  the 
heart  aspirating  the  blood  from  the  veins,  after  a  labored  systole 
caused  by  extensive  pericardial  adhesions. 

Palpation  may  be  of  further  service  in  aiding  inspection  of  the 
veins,  as  in  determining  whether  a  pulsation  is  carried  beyond  the 
sinus  of  the  jugular  vein.  Thus,  in  tricuspid  regurgitation,  a  systolic 
thrill  may  be  felt  over  the  position  of  the  incompetent  valves.  Again, 
in  rare  cases,  the  backward  undulation  may  be  visible  and  palpable 
in  the  thyroid,  external  jugular,  and  facial  veins,  or  a  pulsation  may 
be  propelled  into  the  larger  venous  trunks  of  the  arms,  as  the  axillary, 
brachial,  and  cephalic  and  basilic  veins.  Moreover,  it  is  not  very 
unusual  to  find,  in  such  instances,  a  venous  pulsation  propagated 
down  the  inferior  vena  cava  into  the  veins  of  the  liver,  so  that  palpa- 
tion of  that  organ  detects  a  rhythmic  pulsation — the  venous  liver  pulse 
—following  closely  the  apical  stroke.  The  systolic  swelling  and  dias- 
tolic collapse  may  be  the  more  evident  because  of  the  congested  con- 
dition of  the  organ  which  is  common  in  these  cases,  with  moderate 
enlargement.  This  sign  is  best  elicited  by  grasping  the  whole  right 
lower  zone  of  the  chest,  one  hand  being  placed  with  the  fingers  below 
the  tenth,  eleventh,  and  twelfth  ribs  behind,  and  the  other  in  front 
over  the  hypochondrium  and  epigastrium. 


346  PHYSICAL    DIAGNOSIS 

In  the  diagnosis  of  the  systolic  or  positive  venous  pulse,  it  should 
be  pointed  out  here  that  besides  tricuspid  insufficiency,  it  may  he 
indicative  of  combined  mitral  insufficiency  and  patulous  foramen 
ovale,  or  of  the  extremely  rare  varicose  aneurism  of  the  thoracic 
aorta  communicating  with  the  superior  cava. 

Venous  Pulse  of  Quincke. — This  has  been  described  as  observed 
particularly  in  the  superficial  veins  of  the  hand  and  the  back  of  the 
foot,  in  connection  with  aortic  insufficiency  and  the  capillary  pulse. 
It  represents  probably  the  arterial  pulse  propagated  through  the  capil- 
laries; hence  the  term,  also,  of  progressive  venous  pulse.  This  pulsa- 
tion may  be  associated  with  simple  relaxation  of  the  arteries,  with 
phthisis,  neurasthenia,  and  anemia,  and  is  reported  to  have  been  seen 
in  health  (?). 

A  venous  thrombosis  may  be  detected  on  palpation  in  one  of  the 
larger  veins  of  the  extremities.  The  veins  feel  firm  and  cordlike, 
and  are  usually  surrounded  by  some  local  edema.  This  is  not  a  rare 
complication  of  typhoid  fever,  septic  infections,  and  of  senility. 

AUSCULTATION 

The  only  phenomenon  of  importance  is  the  venous  hum  or  bruit 
de  diable  heard  over  the  jugulars.  This  murmur  may  be  physiologic, 
stethoscopic,  or  pathologic  in  origin;  usually  the  last.  The  jugular 
bulb  sound  of  Bamberger  will  be  referred  to  shortly. 

The  Venous  Hum. — This  is  a  soft,  continuous  humming  or  blow- 
ing sound  heard  over  the  jugular  veins,  but  with  greater  distinctness 
on  the  right  side.  At  times  the  sound  has  a  buzzing  or  even  musical 
quality.  As  it  occurs  almost  exclusively  in  the  internal  jugular  vein, 
it  is  best  heard  in  the  hollow  above  the  clavicle  and  between  the 
origins  of  the  sternocleidomastoid  muscle,  right  over  the  bulbus.  That 
the  murmur  is  venous  and  not  arterial  can  be  demonstrated  by  press- 
ing firmly  on  the  dilated  lower  end  of  the  jugular  vein,  just  above 
the  clavicle,  when  the  hum  will  disappear  at  once.  Again,  pressure 
upon  the  carotid  higher  up  on  the  neck  does  not  alter  the  character 
or  intensity  of  the  venous  murmur. 

The  occurrence  of  the  venous  hum  physiologically  is  accounted 
for  mostly  by  the  anatomic  conditions.  In  the  first  place,  it  may 
be  due  to  the  rush  of  blood  from  the  narrow  vein  into  the  wider 
chamber  of  the  jugular  bulb;  or,  and  in  addition,  as  Hamernjk  has 
shown,  it  may  be  attributed  to  the  considerable  bend  which  the  inter- 
nal jugular  vein  makes  in  a  forward  direction,  in  front  of  the  trans- 


EXAMINATION    OF    THE    BLOOD-VESSELS         347 

verse  process  of  the  sixth  cervical  vertebra,  and  to  the  pressure  of 
the  traversing  omohyoid  muscle.  Doubtless  the  vibrations  are  at  least 
partly  due  to  the  venous  walls  themselves.  By  turning  the  patient's 
head  to  the  opposite  side,  and  thus  putting  the  muscles  on  the  stretch 
on  the  side  under  examination,  the  slightly  audible  hum  may  be 
increased  in  loudness. 

The  intensity  is  influenced  by  other  conditions.  The  pressure  of 
the  stethoscope  develops  or  augments  it.  Likewise,  anything  which 
accelerates  the  flow  of  blood  from  the  jugulars,  as  during  deep  in- 
spiration, the  standing  instead  of  the  sitting  or  lying  posture,  the 
period  of  the  heart  cycle — since,  naturally,  the  murmur  would  be 
weaker  during  the  cardiac  systole,  diastolic  intensification  may  be 
noted.  To  detect  the  venous  hum,  or  variations  in  its  intensity,  it 
is  well  to  have  the  patient  hold  his  breath,  so  as  to  avoid  the  con- 
fusing tracheal  sounds.  The  murmur  is  sometimes  heard  over  the 
upper  part  of  the  sternum,  and  may  even  be  traced  as  far  as  the 
aortic  area  in  certain  instances. 

Pathologically,  the  venous  hum  is  commonly  significant  of  the 
anemias,  especially  of  chlorosis  and  pernicious  anemia.  In  some  rare 
cases  a  venous  murmur  may  be  heard  over  the  femoral  veins,  and  this 
may  be  intensified  by  elevating  the  limb.  In  weakened  and  varicose 
conditions  of  the  femoral  veins,  or  when  the  valves  are  insufficient 
or  absent,  a  sharp,  whizzing  murmur  may  be  excited  by  violent  cough- 
ing, and  may  even  be  palpable  over  the  femoral  vein,  just  below 
Poupart's  ligament.  It  is  probable  that  the  venous  hum  of  anemia  is 
caused  largely  by  the  vibrations  set  up  on  account  of  the  diminished 
quantity  and  plasticity  of  the  blood,  the  currents  being  thus  more 
readily  and  more  forcibly  produced. 

Intermittent  venous  lium  has  been  distinguished  from  the  con- 
tinuous by  Weil,  Guttmann,  and  others.  It  is  of  comparatively  rare 
occurrence,  however.  It  may  be  indicative  of  augmentation  of  the 
jugular  velocity  of  blood  due  to  inspiration,  to  cardiac  diastole,  or  to 
both  combined. 

Jugular  sound,  heard  over  the  bulbus,  as  discovered  by  von  Bam- 
berger,  signifies  the  shock  against  the  valve  in  consequence  of  the 
reflux  wave  of  a  tricuspid  insufficiency.  This  venous  sound  passes 
into  a  murmur  when  the  venous  valve  becomes  incompetent.  Earely 
such  valve  sounds  may  also  be  heard  over  the  femoral  veins,  in  the 
exceptional  instances  when  the  recurrent  waves  reach  these  vessels. 
As  pointed  out  by  Friedreich,  the  sounds  may  be  double,  presumably 
due  to  auricular  as  well  as  ventricular  contraction. 


SECTION   IV 
SPECIAL   PHYSICAL   DIAGNOSIS 


DISEASES  OF  THE  HEART,  INDUCTIVELY  CONSIDERED 

ACTUAL  and  hypothetical  cases  of  heart  disease  will  be  narrated 
in  brief,  typical,  and  suggestive  symptomatic  outline.  The  physical 
signs  will  then  be  stated,  and  the  method  of  analysis,  and  direct  and 
differential  diagnosis  followed  as  in  practical  procedure. 

Case  No.  1. — A  day-laborer,  aged  forty-six,  was  admitted  into 
the  hospital  ward.  He  walked,  complaining  of  and  manifesting  short- 
ness of  breath,  some  precordial  distress,  though  not  actual  pain,  and 
palpitation  of  the  heart.  The  dyspnea  was  quite  marked  on  walking 
rapidly  or  going  up-stairs,  and  for  two  weeks  his  work  as  a  dirt- 
shoveler  bore  so  hardly  upon  him  that  he  had  to  quit  it.  He  showed 
anxiety  and  nervousness  of  countenance  and  manner,  and  weakness 
of  attitude  and  musculature.  His  lips  and  cheek  eminences  had  a 
faint  bluish  tint,  and  his  nostrils  dilated  visibly  with  labored  inspira- 
tion. He  gave  a  history  of  having  had  acute  inflammatory  (articular) 
rheumatism  for  six  weeks,  when  nineteen  years  old,  and  a  mild  attack 
for  two  weeks  just  four  months  previous  to  admission.  His  health 
and  strength  had  been  generally  good  until  the  last  attack,  but  since 
then  he  had  noticed  a  slight,  progressive  loss  of  health  and  endurance, 
frequent  discomforts  after  eating,  with  occasional  eructations  and 
nausea,  constipation,  a  little  cough  after  exertion,  and  momentary 
dizziness  when  fatigued.  He  was  a  "  moderate  "  user  of  beer,  whisky, 
and  pipe-tobacco. 

PHYSICAL  SIGNS. — Inspection  of  the  precordium  showed  no  undue 
prominence  or  depression.  There  was,  however,  a  diffuse,  wavy  im- 
pulse in  the  third,  fourth,  and  fifth  interspaces,  to  the  left  of  the 
sternum,  and  distinct  pulsation  in  the  epigastrium.  The  apical  im- 
348 


DISEASES    OF    THE    HEAET  349 

pulse  was  also  somewhat  increased  in  area,  and  displaced  to  the  left, 
the  center  being  about  ^  in.  beyond  the  nipple  (midclavicular)  line, 
in  the  fifth  interspace. 

Palpation. — This  confirmed  the  information  obtained  visibly,  and 
added  the  following  signs:  The  precordial  and  apical  and  epigastric 
pulsations  were  also  feeble;  the  apex  could  be  located  more  positively 
by  the  finger-tip  near  the  middle  of  a  moderately  diffuse  and  weak 
impulse;  slight  impulse  was  noted  also  in  the  second  left  interspace 
near  the  sternum.  There  was  a  perceptible  but  faint  systolic  thrill 
at  the  apex.  The  pulse  was  diminished  in  volume,  moderately  weak 
or  small,  the  tension  lessened,  and  a  trifle  irregular  as  to  time,  volume, 
and  force. 

Percussion. — The  cardiac  area  of  dulness  (deep  or  relative)  was 
increased  in  all  directions:  to  the  left,  |  in.  beyond  the  nipple-line 
in  the  fifth  interspace,  and  to  the  nipple-line  in  the  third  and  fourth 
interspaces;  to  the  right,  a  trifle  beyond  the  right  border  of  the 
sternum ;  above,  it  begins  with  absolute  dulness  in  the  third  interspace, 
parasternal  line,  thus  making  a  broad  and  rounded  upper  and  outer 
border  of  dulness;  below,  there  could  be  demonstrated  a  diminution 
of  sternal  resonance  at  the  base  of  the  ensiform  process. 

Auscultation. — Both  heart  sounds  were  weakened,  the  first  rela- 
tively more  than  the  second,  which  could  be  heard  quite  distinctly 
at  the  apex.  The  pulmonic  second  sound  was  clearly  accentuated  in 
intensity,  and  of  equal  pitch  with  the  aortic  sound.  The  first  sound 
was  partially  obscured  by  a  soft  systolic  murmur,  maximum  intensity 
over  the  apex;  the  loudness  was  increased  when  the  patient  assumed 
the  dorsal  position.  The  murmur  was  audible  nearly  as  far  as  the 
left  sternal  border,  quite  so  up  to  the  third  interspace,  and  was  trans- 
mitted outward  as  far  as  the  anterior  axillary  region,  with  rapidly 
diminishing  intensity.  Once  or  twice,  after  some  exertion  in  rising 
quickly,  the  murmur  was  heard  faintly  near  the  angle  of  the  left 
scapula. 

DIAGNOSIS  FROM  THE  ANALYSIS  OF  THE  PRECEDING. — In  the  first 
place,  that  we  are  dealing  with  a  heart  case  is  inferred  from  the 
rheumatic  history  and  the  gradual  onset  of  breathlessness,  aggravated 
by  exertion,  along  with  palpitation,  precordial  distress,  and  slight 
cyanosis.  A  history  of  articular  rheumatism  in  itself  should  point 
to  the  probability  of  a  chronic  valvular  endocarditis,  from  its  well- 
known  frequency  as  the  principal  cause.  The  novice  might  be  inclined 
to  surmise  the  case  to  be  one  of  spasmodic  (bronchial)  asthma:,  but 
the  sudden,  brief,  sharp,  expiratory  character  of  the  latter  form  of 


350  rilVSK'AL    DIAGNOSIS 

dyspnea,  its  frequent  occurrence  at  night,  the  prominence  of  cough, 
its  intermissions,  the  absence  of  "local  cardiac  symptoms  and  of  a 
cardiopathic  history,  serve  to  distinguish  this  from  the  so-called 
cardiac  "  asthma." 

Secondly,  we  infer  moderate  enlargement  of  the  heart  because 
of  the  displaced  apex-beat  and  increase  of  the  area  of  dulness. 

Thirdly,  this  enlargement  is  most  probably  caused  by  dilation 
rather  than  hypertrophy,  at  least  by  the  predominance  of  dilation, 
because  of  the  diffuse  impulse  and  outward  rather  than  downward 
displacement  of  the  apex;  since  such  broad  impulse,  laborious  in 
manner,  with  weak,  small  pulse,  is  evidence  of  ventricular  weakness 
associated  with  consequent  yielding  of  the  walls.  In  hypertrophy, 
too,  the  apex  would  be  more  downward,  and  concentrated  in  area 
of  impulse. 

Fourthly,  the  enlargement  or  dilation  involves  the  two  ventricles 
and  the  left  auricle  from  the  facts  of  percussion,  inspection,  and 
palpation,  namely,  outward  and  inward  extension  of  dulness,  as  well 
as  upward  to  the  left  of  the  sternum;  the  apical  impulse  displaced 
to  the  left  (left  ventricle) ;  diffuse  impulse  below  the  third  rib,  into 
the  epigastrium  (right  ventricle),  and  impulse  in  the  third  left  inter- 
space near  the  sternum,  which  may,  however,  be  attributed  partly  to 
a  dilated,  throbbing  pulmonary  artery,  as  well  as  left  auricle. 

Fifthly,  by  auscultation  alone  we  determine  an  insufficiency  of 
the  mitral  valve  from  the  facts  that  the  murmur  is  best  heard  at  the 
apex,  where  mitral  murmurs  have  their  maximum  intensity;  that  its 
systolic  rhythm  occurs  at  the  time  when  the  mitral  valve  should 
normally  be  closed,  and  that  its  propagation  into  the  left  axilla  means 
a  regurgitation  of  blood  backward  from  the  left  ventricle  into  the 
left  auricle. 

A  rational  interpretation  of  the  physical  pathology  from  the  phys- 
ical signs  confirms  the  diagnosis  of  a  mitral  leakage  (chronic),  and 
thus  explains  the  anatomic  and  functional  effects  of  the  lesion.  Thus : 

(1)  The  left  auricle,  the  chamber  which  receives  the  regurgitating 
blood,  is  naturally  subjected  to  increased  pressure,  receiving  also,  as 
it  does,  the  normal  flow  from  the  pulmonary  vein.     This  produces 
first  a  dilation,  then  compensatory  hypertrophy,  then  more  dilation, 
to  be  succeeded  perhaps  by  more  hypertrophy  and  dilation,  and  so  on 
until  permanent  enfeeblement  and  dilation  of  the  auricular  walls 
ensues;  hence  the  extension  of  cardiac  dulness  over  that  region. 

(2)  While  hypertrophy  of  the  left  auricle  predominates,  so  that 
the  increased  quantity  of  blood  received  during  diastole  is  forcibly 


DISEASES    OF    THE    HEART  351 

returned  to  the  left  ventricle  by  the  auricular  systole,  the  effect  may 
be  felt  somewhat  by  the  ventricular  walls,  which  then  respond  to  the 
extra  labor  by  beginning  hypertrophy  also.  The  physical  evidence 
of  this,  which  is  limited  practically  to  a  slight  outward  displacement 
of  the  apical  impulse,  is  seen  only  in  early  cases. 

(3)  Next,  as  auricular  weakness  and  dilation  become  extreme, 
backward  pressure  into  the  pulmonary  veins  occurs;  engorgement  of 
the  pulmonary  capillaries  and  arteries  follows,  and  the  result  is  dila- 
tion from  overdistention  of  the  right  ventricle,   and  more  or   less 
prompt  and  effective  hypertrophy,  which  after  a  long  interval  passes 
into  marked  weakening  and  dilation  of  its  walls  in  turn.     Therefore 
the  diffuse,  flabby  impulse  over  the  lung-exposed  portion  of  the  heart, 
the  marked  epigastric  pulsation,  and  the  cardiac  dulness  to  the  right 
of  the  sternum. 

(4)  During  the  predominance  of  right  ventricular  hypertrophy, 
however,  the  blood  is  forced  forward  with  proper  flow,  so  that,  again, 
an   overdistended   left   auricle   is   throwing   augmented    strain   upon 
the  left  ventricle,  which  then  progressively  enlarges  in  hypertrophic 
dilation,  and  thus  accounts  for  left   (and  often  slightly  downward) 
apical  displacement,  and  increased  area  of  cardiac  dulness  to  the 
left. 

(5)  In  the  last  stages  (which  the  patient's  case  here  cited  does 
not  present),  the  dilation  of  the  right  ventricle  to  a  sufficient  degree 
causes  leakage  of  the  tricuspid  orifice   (relative  insufficiency) ;  the 
flow  of  blood  from  the  right  auricle  to  the  right  ventricle  is  impeded ; 
dilation,  slight  hypertrophy,  and  again  dilation  of  the  auricle  follow, 
and  the  visceral  and  peripheral  venous  congestions,  as  of  the  liver  and 
portal  circulation,  legs,  etc.,  become  gradually  manifest,  with  conse- 
quent dropsical  effusions  into  the  peritoneal  sac   (ascites),  and  the 
edematous  swellings  so  characteristic  below  the  knees,  with  smooth, 
shining,  bluish  pallor  of  skin,  and  the  pit  marks  of  finger  pressure. 

DIFFERENTIAL  DIAGNOSIS. — Mitral  regurgitation  is  seldom  con- 
founded with  other  valvular  lesions,  although  the  murmur  of  aortic 
obstruction  or  roughening,  or  of  tricuspid  regurgitation,  may  simulate 
that  of  the  mitral  lesion.  But  the  associated  physical  signs,  and  the 
bearing  of  the  etiologic  history  and  secondary  effects  of  the  valvular 
derangement  serve  at  once  as  a  check  upon  or  confirmation  of  the 
indication  of  the  murmur  alone.  The  diagnosis  cannot  properly  or 
precisely  be  made  by  the  detection  of  a  murmur  merely. 

Functional  murmurs,  and  those  of  relative  mitral  insufficiency., 
are  more  likely  to  simulate  the  organic  mitral  defect  than  the  organic 


352  PHYSICAL    DIAGNOSIS 

affections  of  the  other  valves.  The  principal  points  of  differentiation 
have  already  been  described  in  a  general  way.  It  should  be  remem- 
bered, however,  that  the  functional  murmurs  are  usually  much  softer 
and  more  variable  in  loudness  than  the  organic;  that,  although  they 
may  be  audible  inside  or  outside  the  apex-beat  (Potain),  more  often 
they  have  their  maximum  intensity  at  the  pulmonic  area;  that  they 
are  not  associated  with  enlarged  area  of  cardiac  dulness  or  secondary 
pulmonary  or  general  venous  congestions  or  accentuation  of  the  pul- 
monic second  sound,  and  that  they  are  localized  instead  of  trans- 
mitted. The  murmur  of  relative  mitral  insufficiency,  which  some- 
times occurs  in  the  course  of  acute  febrile  diseases  from  temporary 
weakness  of  the  myocardium,  may  be  mistaken  for  the  endocardilic 
lesion  at  the  same  orifice.  During  the  course  of  acute  inflammatory 
attacks,  in  particular,  it  is  impossible  to  determine  whether  a  .-ystolic 
murmur  is  due  to  relative  insufficiency  at  the  auriculoventricular 
orifices  or  to  the  beginning  of  a  structural  valvular  change  causing 
leakage.  Even  later,  for  some  time  during  and  after  convalescence, 
anemia  may  cause  a  soft,  blowing  murmur  simulating  an  incipient 
organic  mitral  regurgitation,  until  the  cure  of  the  blood  deficiency 
causes  the  former  to  disappear  and  clear  the  diagnosis. 

Other  conditions  in  which  a  relative  mitral  regurgitant  murmur 
may  occur  should  be  mentioned  in  connection  with  the  resources  of 
differential  diagnosis.  Such  are  fatty  heart,  cardiac  enlargement  of 
chronic  Bright's  disease,  myocarditis,  and  toxemic  disorders.  These 
murmurs  are  also  variable  in  intensity,  being  especially  affected  by 
respiration  and  posture,  and  often  disappearing,  temporarily  at  least, 
under  treatment  with  digitalis.  Also  the  heart  sounds  are  more  fre- 
quently and  decidedly  weak  and  irregular.  A  relative  insufficiency 
murmur  at  the  mitral  orifice  may,  it  is  true,  be  superadded  to  a  real 
organic  lesion  of  the  same,  but  the  latter  is  sure  to  remain  after 
the  therapeutic  test  just  referred  to. 

From  aortic  stenosis,  which  also  has  a  systolic  murmur,  mitral 
regurgitation  may  be  differentiated  by  the  fact  that  the  murmur  pro- 
duced by  the  former  lesion,  even  when  heard  pretty  much  all  over  the 
precordium,  nevertheless  has  its  area  of  greatest  intensity  at  the  sec- 
ond right  interspace;  that  it  is  not  likely  to  be  transmitted  to  the 
left  axilla,  still  less  to  the  left  scapula,  but  rather  is  well  heard  up 
in  the  carotids,  where  the  mitral  murmur  is  inaudible;  that  it  is 
usually  harsher  in  quality  than  the  latter;  and  that  only  in  the  very 
later  stages  is  it  accompanied  with  secondary  venous  congestive  effects 
in  the  pulmonary  and  peripheral  circulations  (from  relative  mitral 


DISEASES    OF    THE    HEAKT  353 

insufficiency  due  to  the  prolonged  strain  upon  the  left  ventricle,  and 
consequent  dilation). 

Tricuspid  re  gurgitation  produces  a  systolic  murmur,  heard  also 
at  the  apex,  but  louder  near  the  sternum  and  an  interspace  higher, 
while  the  mitral  murmur  diminishes  in  intensity  in  that  direction, 
and  is  heard  with  distinctness  beyond  the  left  border  of  the  heart. 
If  any  error  is  made  it  is  rather  in  failing  to  detect  the  concomitant 
tricuspid  murmur,  which  is  practically  always  secondary  to  mitral 
disease.  When  present,  however,  there  is  less  likely  to  be  accentuation 
of  the  pulmonic  second  sound;  and  usually  associated,  on  the  other 
hand,  the  venous  phenomena  already  described  in  the  preceding 
chapter. 

Having  thus  differentiated,  and  excluded  the  possibility  of  con- 
fusing, pericardial  and  cardiorespiratory  murmurs  (q.  v.},  the  diag- 
nosis of  organic  mitral  insufficiency  is  made. 

In  examinations  for  life-insurance  it  frequently  happens  that  a 
very  slight  degree  of  mitral  regurgitation  is  discovered  on  ausculta- 
tion, but  which,  so  far  as  symptoms  are  concerned,  the  applicant  is 
unaware  of,  and  which  may  not  be  signally  aggravated  to  loss  of 
myocardial  compensation  for  fifteen  or  twenty  years  in  a  person  of 
early  or  middle  life,  and  of  moderate  habits  and  work  and  tranquil 
mentality. 

Case  No.  2. — A  slender,  almost  phthisical-looking  woman  of  twen- 
ty-seven years,  with  a  history  of  having  had  several  rheumatic  attacks 
since  childhood,  complains  of  rapidly  increasing  breathlessness  and 
palpitation  of  the  heart  within  a  month  of  consultation.  These  symp- 
toms were  especially  distressing  on  exertion,  and  were  accompanied 
with  pain  in  the  left  side  of  the  chest,  and  a  short,  dry  cough.  The 
face  is  pale,  with  a  bluish  duskiness  of  the  cheeks,  lips,  and  slightly 
clubbed  finger-tips.  The  insteps  and  ankles  are  slightly  edematous. 
Dyspepsia  (sour  eructations  being  troublesome),  constipation,  scanty 
urine  and  menses,  vertigo,  and  sleeplessness  are  also  complained  of. 
A  bronchitis  was  suffered  from  the  previous  winter,  and  twice  blood- 
tinged  expectoration  was  noticed. 

PHYSICAL  SIGNS. — Inspection  of  the  precordium  notes  a  decided 
bulging  of  the  lower  part  of  the  sternum,  and  of  the  fourth  inter- 
space, fifth  rib,  and  fifth  interspace,  over  the  normal  position  of  the 
right  ventricle.  In  the  same  region  there  is  visible  pulsation,  diffuse 
and  fluttery;  also,  slightly,  in  the  second  and  third  left  interspaces, 
but  a  little  more  prominently  in  the  epigastrium.  The  apex  impulse 
is  just  noticeable,  and  not  displaced. 
25 


354  PHYSICAL    DIAGNOSIS 

Palpation. — By  this  method  the  visible  signs  are  confirmed :  over 
the  body  of  the  heart,  where  the  diffuse  pulsations  are  noted,  the 
hand  feels  a  wavy  fluttering,  with  an  occasional  laborious  heave;  the 
epigastric  pulsation  is  palpable,  and  a  slight  impulse  is  felt  in  the 
second  left  interspace  near  the  sternum.  In  addition,  the  apex-beat 
is  perceptibly  weak,  and  felt  in  the  fifth  interspace  in  the  midclavicu- 
lar  line.  Characteristic,  however,  is  a  thrill,  presystolic,  felt  over  the 
apex;  it  has  a  short,  slightly  rough,  purring  quality,  running  up  to 
and  terminating  abruptly  with  the  apex-beat,  which  follows  imme- 
diately as  a  sharp  shock  or  thump.  The  thrill  is  more  marked  during 
expiration. 

The  pulse  is  distinctly  small,  soft,  weak,  and  irregular  in  regard 
to  the  rhythm,  thus  being  synchronous  with  the  cardiac  impulse,  which 
in  its  irregularity  seems  at  times  to  be  a  prolongation  of  the  thrill. 

Percussion. — The  area  of  deep-seated  cardiac  dulncss  is  increased 
transversely,  especially  to  the  right,  as  far  as  one  inch  beyond  the 
right  sternal  line  in  the  third,  fourth,  and  fifth  interspaces;  upward 
along  the  left  edge  of  the  sternum,  a  few  fingerbreadths  beyond  in 
extent,  as  far  as  the  second  interspace.  Dulness  is  also  marked  over 
the  lower  half  of  the  sternum,  and  in  the  epigastrium  around  the 
xiphoid. 

Auscultation. — The  heart  sounds  are  weak  at  the  base,  and  some- 
what irregular  in  rhythm.  The  first  sound  at  the  apex  is  short, 
valvular,  slapping  in  character,  and  preceded  by  a  rough,  blubbering 
murmur.  The  second  sound  is  very  distinct  at  the  base,  and  espe- 
cially loud  and  accentuated  at  the  pulmonic  orifice.  On  the  other 
hand,  the  aortic  sound  is  actually  and  relatively  weak.  Both  sounds 
are  heard  separately  on  account  of  a  barely  perceptible  interval ;  that 
is,  the  second  is  reduplicated  or  divided.  The  diastolic  interval 
between  the  second  and  first  sounds  seems  to  be  prolonged. 

The  murmur  is  a  long  one,  beginning  early  during  diastole,  but 
reaching  its  climax  of  roughness  and  intensity  just  before  ventricular 
systole — presystolic,  therefore,  and  synchronous  with  the  thrill.  It  is 
practically  limited  in  audibility  to  an  area  about  the  apex  not  more 
than  two  and  one-half  inches  in  diameter,  and  is  not  transmitted. 
The  murmur  sounds  very  like  a  whispered  roll  of  the  letters  r-r-r-b, 
stopping  suddenly  with  the  sharp,  tapping  first  sound. 

ANALYSIS. — First,  we  have  here  evidently  a  serious  organic  car- 
diac affection,  judging  from  the  rheumatic  history  in  conjunction 
with  the  symptoms,  subjective  and  objective,  of  impaired  and  unbal- 
anced circulation. 


DISEASES    OF    THE    HEART  355 

Secondly,  there  is  undoubted  dilation  of  at  least  two  of  the  cardiac 
chambers,  namely,  the  left  auricle  and  the  right  ventricle,  because 
of  the  location  and  character  of  the  pulsations  noted  by  inspection  and 
palpation,  and  because  of  the  percutory  outlines  of  dulness.  At  the 
same  time,  important  negative  evidence  as  to  the  left  ventricle  is  to 
be  considered  in  respect  to  the  absence  of  dulness  to  the  left,  and  the 
position  and  weakness  of  the  apex-beat. 

Thirdly,  the  presystolic  thrill  and  murmur  localized  at  the  apex 
indicate  the  valvular  or  orificial  difficulty  to  be  mitral,  and  obstruct- 
ive in  nature,  because  these  signs  occur  at  the  time  when,  normally, 
this  auriculoventricular  opening  is  free  for  the  blood  to  pass  from 
the  left  auricle  into  its  fellow  ventricle,  but  in  this  case  is  not  so, 
by  reason  of  the  palpable  and  audible  disturbances  set  up  at  this  time. 

The  DIAGNOSIS,  therefore,  is  mitral  obstruction  or  stenosis. 

The  PHYSICAL  PATHOLOGY  is  similar  to  that  of  the  preceding 
case  of  mitral  regurgitation,  so  far  as  the  dilation  of  the  auricle 
and  ventricle  are  concerned.  Here  the  pulmonary  circulation  is  con- 
gested because  the  blood  is  prevented  from  getting  into  the  systemic 
circulation  except  under  great  difficulty,  being  held  back  from  the 
left  ventricle  by  the  mitral  constriction,  whereas  in  the  other  instance 
it  was  forced  backward  through  the  leaking  valve  by  the  contracting 
ventricle. 

Hence,  too,  since  the  left  ventricle  in  mitral  stenosis  has  less  than 
the  normal  quantity  of  blood  to  circulate,  it  is  inclined  to  atrophy 
and  shrink  behind  the  right  ventricle,  which  is  hypertrophied  from 
too  much  work  to  do.  That  the  pressure  in  the  pulmonary  circula- 
tion is  also  above  normal  is  indicated  by  the  accentuation  of  the  pul- 
monic  sound,  and  especially  by  the  comparatively  higher  pitch  than 
the  aortic,  showing  the  relatively  lower  tension  in  the  aorta.  That  the 
left  ventricle  is  incompletely  supplied  with  blood  is  likewise  evidenced 
by  the  weak  apex-beat  and  the  small  and  weak  pulse. 

The  fact  that  the  full  intensity  of  the  murmur  is  heard  just 
before  systole,  although  somewhat  audible  at  the  middle  of  diastole, 
proves  obstructive  difficulty  at  the  mitral  orifice,  since  at  this  latter 
portion  of  diastole  the  auricular  systole  produces  vibrations  of  suffi- 
cient strength  to  be  well  heard,  while  the  moderate  speed  with  which 
the  blood  flows  through  the  narrowed  orifice  in  the  first  half  of  diastole 
is  insufficient  to  cause  such  vibrations. 

DIFFERENTIAL  DIAGNOSIS. — Mitral  regurgitation  may  be  associ- 
ated with  mitral  stenosis,  but  the  murmur  may  be  recognized  by  its 
being  softer  and  lower  in  pitch,  beginning  with  the  first  sound  and 


356  PHYSICAL    DIAGNOSIS 

diminishing,  as  well  as  being  transmitted  to  the  axilla,  instead  of 
having  a  crescendo  of  intensity  up  to  the  first  sound,  and  then  ceasing 
abruptly.  Presystolic  thrill  is  more  common  than  the  systolic  thrill 
of  insufficiency  also.  In  mitral  stenosis,  doubling  of  the  second  sound 
is  not  only  more  common  than  in  mitral  regurgitation,  at  the  base, 
but  is  not  infrequently,  as  an  apparent  doubling,  heard  over  the 
mitral  area  as  well;  the  causation  of  the  latter,  however,  is  different 
from  that  of  the  former.  Again,  in  mitral  obstructive  disease  there 
is  more  extension  of  dulness  to  the  right  than  in  the  regurgitant 
form,  and  none  to  the  left  as  in  that.  Finally,  the  pulse  is  decidedly 
more  diminished  in  volume  and  force  in  stenosis,  and  arhythmia 
is  more  marked. 

Tricuspid  stenosis  produces  a  murmur  heard  almost  in  the  same 
situation  as  that  of  the  mitral  lesion,  and  having  an  identical  time 
and  quality.  But  the  rarity  of  the  tricuspid  affection  seldom  calls 
for  its  differentiation. 

Aortic  regurgitation  has  a  diastolic  murmur  beginning  with  the 
second  sound,  which  the  mitral  stenotic  seldom  does,  and  dies  away, 
while  the  latter  increases  up  to  the  first  sound.  Again,  the  aortic 
regurgitant  murmur  is  usually  very  soft  and  smooth  in  quality,  heard 
near  the  second  right  interspace,  and  transmitted  down  along  the 
sternum,  although  cases  sometimes  occur  where  a  typical  presystolic 
murmur  of  rolling  quality,  with  thrill,  is  nevertheless  shown  post 
mortem  to  have  been  caused  by  aortic  regurgitation,  and  not  mitral 
stenosis — the  so-called  "  Austin  Flint  murmur."  Here  the  diagnosis 
may  be  made  by  noting  whether  there  is  marked  enlargement  of  the 
left  ventricle,  which  would  point  to  aortic  insufficiency,  especially  if 
at  the  same  time  there  is  weak  second  sound  and  loud  first  sound, 
the  reverse  of  mitral  obstruction,  which  has  a  short,  snapping  first 
and  an  accentuated  and  often  reduplicated  second  sound.  The  differ- 
ences in  the  areas  and  directions  of  extent  of  cardiac  dulness,  and  of 
the  positions  of  the  apex-beat,  are  also  important. 

Pericardial  friction,  especially  when  due  to  adherent  pericardium, 
may  simulate  mitral  stenosis;  but  the  murmur  is  seldom  limited  to 
presystolic  time,  has  a  superficial,  short,  scratching  sound,  and  is 
inconstant ;  the  first  sound  at  the  apex,  also,  is  weakened  or  indistinct 
instead  of  accentuated  and  flapping  in  character. 

Case  No.  3. — A  large,  heavily  built  Irishman,  teamster,  fifty-one 
years  of  age,  came  into  the  office  much  oppressed  with  dyspnea,  which 
he  said  came  on  rather  suddenly  about  a  month  or  six  weeks  previ- 
ously. He  was  flushed  with  and  smelled  of  whisky,  which  he  ad- 


DISEASES    OF    THE    HEART  357 

mitted  he  had  been  in  the  habit  of  using  daily  for  thirty  years,  and 
said  that  at  other  times  persons  told  him  he  was  pale.  He  had  always 
worked  hard  at  heavy  lifting  and  the  like,  and  remembered  to  have 
felt  the  effects  of  physical  strain  recently  in  a  sort  of  momentary 
blinding  dizziness,  sense  of  suffocation,  headache,  precordial  distress 
with  some  neuralgic  pains  radiating  to  the  left  shoulder,  followed  by 
faintness,  restlessness,  sweating,  and  considerable  muscular  weakness 
and  general  prostration  lasting  for  a  day  or  two.  He  said  that  when 
a  young  man  he  had  one  attack  of  inflammatory  rheumatism,  which 
affected  only  the  left  knee-joint,  and  which  he  recovered  from  in 
about  two  weeks. 

PHYSICAL  SIGXS. — Inspection  shows  marked  fulness  of  the  fourth 
and  fifth  ribs  and  interspaces  and  the  sixth  rib,  from  the  left  para- 
sternal  line  to  a  little  beyond  the  nipple-line.  The  apex-beat  is  mod- 
erately diffuse,  but  with  heaving  impulse  central  in  the  sixth  inter- 
space, fully  an  inch  and  a  half  outside  the  mammillary  line,  and 
quite  near  the  anterior  axillary.  There  is  visible  over  the  lower  half 
of  the  precordium,  also,  a  general,  slightly  labored  impulse.  Vio- 
lent pulsations,  with  exaggerated  diastolic  collapse  of  the  temporal, 
carotid,  axillary,  brachial,  radial,  ulnar,  femoral,  and  dorsalis  pedis 
arteries,  are  plainly  seen.  The  larger  arteries  mentioned  are  distended 
and  somewhat  tortuous,  the  throbbing  temporals  being  very  serpentine. 

Palpation. — The  whole  hand  applied  recognizes  a  strong,  wide- 
spread cardiac  impulse.  The  apex-beat  occasionally  conveys  the  im- 
pression of  a  double  muscular  movement.  At  times  a  faint  diastolic 
tremor  is  felt  at  the  base  of  the  heart,  near  the  sternum. 

The  pulse  (radial  and  elsewhere)  is  peculiarly  quick  and  sharp 
in  wave  contact,  yet  soft,  and  it  is  hardly  felt  before  it  drops  from 
the  finger  in  as  sudden  and  volatile  a  manner.  The  latter  phenome- 
non becomes  more  distinct  when  the  arm  is  raised.  These  facts  draw 
attention  to  the  capillaries,  which  are  examined  by  inspection,  and 
a  capillary  pulse  is  detected  beneath  the  nails.  There  is  an  occasional 
abortive  radial  pulse-wave. 

Percussion. — The  area  of  cardiac  dulness  extends  downward  and 
outward  from  the  third  interspace  near  the  sternum,  as  far  as  the 
sixth  interspace,  and  about  one  and  one-half  inch  to  the  left  of  the 
nipple-line.  The  dulness  extends  inward  from  thence  to  the  left 
sternal  line,  from  the  xiphoid  to  the  third  rib  cartilage,  and  all  over 
this  enlarged  area  is  marked,  showing  that  there  is  less  than  normal 
amount  of  lung  overlapping,  provided  there  is  no  consolidation  of 
its  tissue. 


358  PHYSICAL    DIAGNOSIS 

Auscultation. — The  heart  sounds:  the  first  sound  is  loud,  and  yet, 
paradoxically,  peculiarly  muffled  or  lacking  in  tone;  the  second  sound 
is  very  feeble  and  fugacious  at  the  aortic  interspace;  the  pulmonic 
sound  is  distinct,  but  not  accentuated. 

Applying  the  stethoscope  carefully,  a  very  soft,  blowing  murmur 
is  heard  at  the  base  of  the  heart,  with  a  maximum  intensity  in  the 
third  left  interspace  at  the  sternal  edge,  although  audible  also  in 
the  corresponding  region  of  the  right  side,  and  at  midsternum  of  the 
same  level.  It  is  synchronous  with  the  second  sound,  and  occupies 
at  least  one-half  of  the  diastolic  interval  following  it.  The  murmur  is 
transmitted  down  the  sternum  as  far  as  the  xiphoid  junction,  and  to 
the  left  as  far  as  the  parasternal  line  in  the  fourth  and  fifth  inter- 
spaces, where  it  is  fairly  audible. 

Over  the  large  throbbing  arteries — the  carotids,  subclavians,  and 
femorals — a  short,  snapping  sound,  systolic;  on  pressure  with  the 
stethoscope  this  is  replaced  by  a  distinct  murmur;  occasionally,  while 
varying  the  pressure,  a  diastolic  murmur  is  also  heard. 

ANALYSIS. — In  the  first  place,  that  we  are  dealing  with  a  heart 
that  is  greatly  enlarged  and  most  laboriously  beating  because  of 
severe  strain  is  evident  from  the  position  and  character  of  the  apcx- 
beat,  the  extent  of  cardiac  dulness,  and  the  visible  pulsations  of  the 
principal  arteries.  For  the  same  reason,  we  know  that  the  bulk 
of  enlargement  is  a  hypertrophic  dilation  of  the  left  ventricle.  This 
must  mean  that  there  is  obstruction  or  insufficiency  at  the  aortic 
orifice  because  of  the  position  of  greatest  intensity  of  the  murmur 
discovered.  And  because  that  murmur  is  diastolic,  and  is  transmitted 
down  the  sternum,  the  lesion  means  a  leakage  at  the  aortic  cusps, 
since  at  that  period  of  the  cardiac  cycle  the  valve  should  be  closed. 
The  sound  and  double  murmurs  in  the  arteries,  and  the  quick,  short, 
water-hammer  pulse  afford  additional  proof  that  there  is  exaggerated 
ventricular  contraction,  and  sudden  diminution  of  intravascular  pres- 
sure instead  of  the  gradual,  sustained  wave  which  indicates  normally 
that  when  the  aorta  is  dilated  with  each  fresh  column  of  blood,  the 
valve  is  able  to  hold  it  until  the  next  systole. 

The  DIAGNOSIS  OF  AORTIC  REGURGiTATiON  is  thus  made. 

The  PHYSICAL  PATHOLOGY  is  patent.  The  constant,  rhythmic  re- 
turn into  the  left  ventricle  from  which  they  have  just  come,  of  regur- 
gitating currents  of  blood,  cannot  but  issue,  as  it  does,  in  enormous 
strain,  since  this  chamber  is  also  as  regularly  receiving  its  usual 
amount  from  the  left  auricle.  A  progressive,  alternating  seesaw 
of  hypertrophy  and  dilation  of  the  left  ventricular  wall  is  thus  set 


DISEASES    OF    THE    HEART  359 

up  which  causes  in  time  the  greatest  known  size  of  heart,  or  cor 
b  ov  in  um. 

Sooner  or  later,  when  dilation  predominates  nearly  permanently 
over  the  hypertrophy,  a  relative  mitral  insufficiency  develops,  with  its 
train  of  consequences  already  described.  The  presence  of  the  double 
murmur  in  the  arteries  (Duroziez's  sign)  is,  as  intimated  by  the 
conditions  explained  above,  virtually  pathognomonic  of  aortic  insuf- 
ficiency. 

DIFFERENTIAL  DIAGNOSIS. — The  differentiation  of  the  mitral  ob- 
structive and  "  Flint  murmurs "  has  already  been  pointed  out  in 
connection  with  the  preceding  case. 

The  interpretation  of  a  diastolic  murmur  at  the  base  of  the  heart 
may  be  difficult  in  the  absence  of  distinctive  arterial  signs  and  the 
evidences  of  left  ventricular  enlargement,  as  in  the  early  cases.  For 
instance,  such  a  murmur  may  be  functional  or  anemic,  although,  it 
is  true,  rarely  so;  it  may  be  due  to  congenital  pulmonary  regurgita- 
tion  (also  rare),  to  aneurism,  to  fatty  and  relaxed  (dilated)  aorta, 
or  to  adherent  pericardium  (Cabot),  and  myocarditis  or  exophthalmic 
goiter  (  Musser).  If  the  murmur  is  hemic,  and  transmitted  downward 
from  the  cervical  veins,  instead  of  aortic  regurgitation,  pressure  over 
the  jugular  bulb  will  obliterate  it.  The  rare  pulmonary  insufficiency 
is  unaccompanied  with  hypertrophy  of  the  left  ventricle,  and  cyanosis 
and  childhood  or  adolescence,  instead  of  pallor  and  advanced  years, 
are  associated  with  it.  Aneurism  has  expansile  pulsation,  often 
tumor,  upper  sternal  dulness,  and  also  the  characteristic  bruit  and 
pressure  phenomena.  Dilated  aorta  usually  gives  an  area  of  dulness 
between  the  first  and  third  ribs  along  the  right  sternal  border. 

Associated  aortic  or  mitral  systolic  murmurs  are  not  infrequent 
with  aortic  regurgitation. 

Aortic  systolic  murmur  may  often  be  heard,  due  to  accompanying 
stenosis  or  roughness  of  the  aorta  or  valve-segments.  This  murmur 
is  usually  harsh  and  high  pitched  as  contrasted  with  that  of  aortic 
insufficiency,  which  is  diastolic;  it  is  transmitted  into  the  carotids 
with  the  same  quality,  but  in  coexistence  with  aortic  regurgitation, 
the  soft  murmurs  in  the  other  arteries  often  associated  with  the 
latter  are  absent;  the  murmur  is  also  heard  over  a  larger  part  of 
the  body  of  the  heart,  in  most  cases,  and  is  accompanied  with  a 
systolic  tremor  or  thrill;  and  lastly,  the  pulse-waves  are  not  so  high 
and  quick,  if  at  all,  as  when  the  insufficiency  is  uncomplicated.  One 
source  of  error  in  inferring  aortic  stenosis  due  to  pathologic  changes 
at  the  orifice,  as  well  as  leakage,  should  be  indicated;  namely,  that 


360  PHYSICAL    DIAGNOSIS 

the  systolic  murmur  may  be  the  result  of  a  "  physiologic  stenosis," 
or  really  the  normally  narrower  aorta  beyond  a  very  widely  dilated 
aortic  orifice,  which  thus  permits  a  large  column  of  blood  to  be  pro- 
pelled into  the  smaller  caliber  with  current  disturbance. 

A  systolic  murmur  in  the  mitral  area  associated  with  the  aortic 
diastolic  is  not  at  all  rare,  both  being  often  heard  distinctly  close 
together  because  of  the  transmission  of  the  latter.  The  mitral  systolic 
is  softer  than  the  aortic  systolic  murmur;  it  is  heard  to  the  left  in 
the  axilla;  the  pulmonic  sound  is  accentuated,  and  secondary  hyper- 
trophy and  dilation  of  the  right  ventricle  appear  later.  The  mitral 
insufficiency  may  be  due  to  a  combined  endocarditis,  or  to  a  relative 
insufficiency,  as  from  dilation  of  the  left  ventricle  from  other  causes. 
Still  later,  a  tertiary  relative  insufficiency  at  the  tricuspid  orifice 
may  develop,  as  evidenced  by  soft  systolic  murmur  heard  best  over  the 
lower  third  of  the  sternum,  and  separated  from  the  area  of  mitral 
regurgitant  murmur  by  a  zone  or  interval  of  feeble  or  absent 
audibility. 


PART  II 


SECTION  V 

GENERAL  EXAMINATION  OP  THE 
ABDOMEN 


CHAPTER    XVI 

TOPOGRAPHIC  ANATOMY,   REGIONS,   AND  METHODS  OF 
ABDOMINAL  EXAMINATION 

ANATOMIC    ZONES,    REGIONS,    AND    LANDMARKS 

FOR  descriptive  purposes  and  the  proper  location  of  abdominal 
physical  signs,  we  use  terms  expressive  of  anatomic  regions  having 
natural  points  of  reference  and  more  or  less  arbitrarily  drawn  limit- 
ing lines.  According  to  the  old  traditional  method,  the  abdominal 
surface  is  divided  into  three  zones  by  two  horizontal  lines  or  imag- 
inary planes,  the  upper  being  called  the  infra-  or  subcostal,  which 
passes  across  at  the  level  of  the  lowest  part  of  the  thorax  (tenth  rib), 
and  the  lower  the  bispinal,  connecting  the  anterior  iliac  spines,  thus 
producing  the  epigastric,  mesogastric,  and  hypogastric  zones.  Sub- 
dividing these  three  zones  by  two  vertical  lines  or  planes  passing 
through  the  middle  of  Poupart's  ligament  on  each  side  (correspond- 
ing practically  to  the  projected  nipple-lines),  we  have  then  nine 
regions  or  spaces,  as  follows: 

Eight  hypochondriac.         Epigastric.  Left  hypochondriac. 

"      lumbar.  Umbilical.  "    lumbar. 

"      iliac.  Hypogastric.  "     iliac. 

The  iliac  regions  are  also  called  sometimes  the  right  and  left 
inguinal.  The  hypochondriac  regions  may  be  made  to  coincide  more 
naturally  by  having  their  inner  and  lower  boundaries  represented  by 
the  curved  lines  of  the  inferior  costal  borders  (Butler).  The  lumbar 
regions  may  be  considered  as  prolonged  around  the  sides  to  the  middle 
of  the  back,  and  subdivided  further  by  the  axillary  lines. 

368 


364 


PHYSICAL   DIAGNOSIS 


Another  regional  division,  much  more  simple  and  satisfactory,  is 
that  of  the  quadrants  devised  by  Ballance,  and  indorsed  especially 
by  Musser.  The  surface  of  the  abdomen  is  thus  divided  by  a  median 


FIG.  75. — SHOWING  NINE  TOPOGRAPHICAL  AREAS  OF  ABDOMEN. 
(After  Joessel.      Redrawn  and  modified.)      (Butler.) 

and  a  transverse  umbilical  line  into  right  and  left  upper  and  right 
and  left  lower  quadrants.  "  The  right  upper  quadrant  contains  the 
right  lobe  of  the  liver,  the  gall-bladder,  the  hepatic  flexure  and  part 
of  the  transverse  colon,  a  portion  of  the  pancreas,  the  pylorus,  near 
the  median  line,  and,  deeper,  the  upper  half  of  the  kidney.  The 
left  upper  quadrant  contains  the  left  lobe  of  the  liver,  the  stomach, 
part  of  the  transverse  colon  and  the  splenic  flexure,  the  pancreas,  the 
upper  portion  of  the  kidney,  and  the  spleen.  The  right  lower  quad- 
rant contains  the  cecum,  the  ascending  colon,  the  appendix  vermifor- 
mis,  the  right  tube  and  ovary,  portions  of  the  bladder  and  uterus, 
and  above,  at  the  end  of  full  inspiration,  the  lower  portion  of  the 


ANATOMY    OF    THE    ABDOMEN 


365 


kidney.  The  left  lower  quadrant  contains  the  corresponding  tube, 
ovary,  and  portions  of  the  bladder  and  uterus,  the  descending  colon, 
and  the  sigmoid  flexure.  It  does  not  usually  contain  the  lower  portion 
of  the  left  kidney,  which  is  one-half  inch  or  more  higher  than  the 
right  (Holden).  About  the  center,  and  extending  to  the  periphery 
on  all  sides,  are  the  small  and  large  intestines." 


FIG.  76. — VISCERA  OF  THE  THORAX  AND  ABDOMEN  AS  SEEN  FROM  BEHIND. 
(After  Luschka:  from  Musser.) 

Similarly,  I  have  found  it  desirable  at  times  to  take  a  middle 
course,  and  divide  the  abdominal  circle  into  sextants,  approximately, 


366  PHYSICAL   DIAGNOSIS 

by  using  three  lines,  one  horizontal  and  two  diagonal  passing  through 
the  navel,  the  latter  practically  connecting  the  axillary  regions  with 
the  middle  of  Poupart's  ligament  on  opposite  sides  (see  Plate  IX). 

The  anatomic  landmarks  are  useful  in  relational  designation,  and 
as  measuring  points  for  locating  physical  signs.  The  most  reliable 
marks  are,  of  course,  the  immovable  or  bony  ones,  especially  the  an- 
terior superior  iliac  spines.  The  ensiform  appendix,  down-curving 
rib  borders,  and  pubic  symphysis  are  also  easily  distinguishable. 

The  other  principal  landmarks  are  the  Hnea  alba,  linece  serniln- 
nares,  linece  transverse,  and  the  umbilicus.  Any  portion  of  the  hori- 
zontal or  vertical  line  drawn  through  the  last  named  may  be  used  as 
a  measuring  basis  to  locate  more  accurately  the  results  of  physical 
examination.  In  determining  the  lower  border  of  the  liver,  or  of  the 
spleen,  when  either  organ  is  enlarged,  we  often  speak  in  terms  of 
one  (f  in.)  or  more  fingerbreadths  below  the  costal  margins. 

The  topographic  anatomy  of  the  abdominal  aorta  needs  a  special 
reference.  The  aorta  extends  from  a  point  midway  between  the 
upper  border  of  the  sternum  and  the  umbilicus,  along  the  left  of 
the  linea  alba  to  its  bifurcation,  about  f  in.  to  the  left  of  and  below 
the  umbilicus,  about  opposite  the  body  of  the  fourth  lumbar  vertebra. 


METHODS    OF    ABDOMINAL    EXAMINATION 

The  relative  importance  and  value  of  the  usual  four  methods  of 
physical  examination  as  applied  to  the  thorax  are  not  the  same  as 
applied  to  the  abdomen;  their  order  is  virtually  reversed  as  regards 
fulness  and  exactness  of  results.  Auscultation  is  rarely  used,  and 
affords  little  of  value;  percussion  may  often  be  of  direct  and  con- 
firmatory value,  but  is  seldom  practised  under  favorable  conditions; 
inspection  and  palpation  elicit  the  more  reliable  signs,  but  even  with 
these  methods,  anatomic,  functional,  and  complicating  restrictions 
sometimes  perplex,  and  prevent  the  determination  of  precise  data. 

GENERAL  INSPECTION 

Technic. — The  patient  should  lie  upon  a  regular  examining  table 
or  chair,  such  as  gynecologists  use,  although  very  often  the  examina- 
tion must  be  made  while  the  patient  is  in  bed.  If  the  latter,  when- 
ever possible  a  narrow  bed  with  firm  but  comfortable  mattress  should 
be  chosen,  and  the  head  supported  upon  a  pillow  so  as  to  elevate  the 
chest  a  little.  Care  should  be  taken  that  the  cervical,  dorsal,  and 


PLATE    IX 


v* 

? 


ABDOMEN    DIVIDED  INTO  SEXTANTS  FOR  THE  LOCALIZATION  OF  PHYSICAL  RKJNS. 


METHODS    OF    ABDOMINAL    EXAMINATION        367 

lumbar  spine  are  kept  straight  in  the  recumbent  position.  Sometimes, 
as  in  observing  the  shape  of  the  abdomen  with  a  view  to  estimating 
how  much  it  may  be  influenced  and  how,  by  movable  organs,  effusions, 
and  growths,  the  erect  posture  of  the  patient  is  necessary.  The  abdo- 
men must  be  exposed  completely,  from  the  lower  borders  of  the  breasts 
to  the  pubes.  It  must  be  viewed,  also,  with  a  good,  somewhat  slanting 
light,  such  as  falls  upon  the  foot  of  the  bed  from  a  window  directly 
opposite  its  head,  and  the  examiner  should  look  from  both  sides  and 
at  various  angles,  so  as  not  to  miss  slight  exaggeration  of  surface 
inequality  and  movement  which  shadows  may  cause.  Heavy  bed- 
clothing  should  not  be  rolled  down  so  as  to  dim  the  light  over  the 
lower  part  of  the  belly,  but  folded  down  far  enough  so  that  there  is 
nothing  more  than  the  thickness  of  a  sheet  or  thin  blanket  to  cover  the 
genitals  and  lower  extremities. 

The  Normal  Abdomen. — Its  contour  in  the  average  individual  of 
medium  build  shows  a  shallow  arching,  with  the  convexity  most 
marked  at  or  near  the  umbilicus  if  the  person  is  lying  down,  or  a 
trifle  below  that  point  if  standing.  After  a  full  meal  the  upper  zone, 
especially  between  the  costal  borders,  may  exhibit  more  than  usual 
prominence.  In  infants  the  abdomen  is  relatively  larger  and  rounder ; 
also  in  women  than  in  men,  with  more  subcutaneous  and  omental  fat. 
In  multiparous  women,  and  in  those  who  have  worn  tightly  fitting 
corsets,  naturally  the  lower  zone  of  the  abdomen  is  more  or  less  relaxed 
and  pendulous — toward  the  flanks  while  recumbent,  and  overhanging 
the  pubes  while  standing  erect. 

In  inspecting  the  abdomen  for  pathologic  signs,  the  following 
points  are  to  be  noted:  (1)  The  size,  shape,  and  general  contour; 
(2)  the  surface  appearances  of  the  belly  walls;  (3)  the  respiratory 
and  peristaltic  movements;  (4)  local  bulgings  or  depressions. 

(1)  SIZE,  SHAPE,  AND  CONTOUR  OF  THE  BELLY. — These  may  be 
considered  together.  General  enlargement  of  the  abdomen  is  usually 
uniform  and  symmetrical.  It  may  be  due  to  (a)  fatty  or  edematous 
thickness  of  the  abdominal  walls;  (&)  usually  to  ascitic  distention 
(dropsy  of  the  peritoneum) ;  (c)  to  gaseous  distention  of  the  intes- 
tines (tympanites),  as  from  peritonitis,  and  in  typhoid  fever;  (d) 
and  to  enormous  organic  or  neoplastic  enlargements  crowding  the 
abdominal  cavity,  such  as  massive  uterine  fibroid,  ovarian  cyst  of 
extreme  size,  big  sarcoma,  great  hepatic  or  splenic  enlargement,  etc. 
In  cases  where  the  enlargement  alters  its  shape  slightly  with  change 
of  posture,  as  increase  in  fulness  of  the  flanks  in  the  recumbent 
position,  and  more  conical  protrusion  forward,  with  the  navel  at  or 
26 


368  PHYSICAL    DIAGNOSIS 

a  trifle  above  the  apex  in  the  erect  position,  ascitic  fluid  is  commonly 
present.  Gaseous  distention  of  the  bowels  does  not  cause  change  of 
abdominal  shape  on  changing  the  patient's  posture.  On  very  close 


FIG.  77. — GENERAL  ENLARGEMENT  OF  THE  ABDOMEN  FROM  ABDOMINAL  DROPSY 
(AsciTEs).     Note  the  turgid,  tortuous  vein. 

inspection,  the  detection  of  slight  asymmetry  in  an  apparently  uni- 
formly enlarged  belly  justifies  the  presumption  of  tumor. 

(2)  Tins  ABDOMINAL  WALLS. — The  various  objective  signs  of  the 
skin  are  concerned  mostly  in  connection  with  general  medical  rather 
than  with  physical  diagnosis  and  the  grosser  signs  also  subject  to  the 
other  methods  of  examination.  Thus,  of  the  color  of  the  skin,  it 
need  only  be  remarked  here  that  its  pallor  or  slightly  dusky  hue,  with 
a  tense,  smooth,  somewhat  glazed  or  sheened  appearance,  is  quite  char- 
acteristic of  ascites.  If  at  the  same  time  a  number  of  enlarged  and 
tortuous  veins  radiating  about  the  navel  (caput  Medusa]  are  seen, 


METHODS    OF    ABDOMINAL    EXAMINATION        369 

and  if  the  umbilicus  levels  up  or  protrudes,  the  presence  of  fluid  in 
the  peritoneal  sac,  due  usually  to  atrophic  cirrhosis  of  the  liver,  is 
undoubted.  S  trice  or  linece  albicantes  may  also  be  seen,  bluish  or 
slightly  reddish  at  first,  as  accompaniments  of  prolonged  skin-stretch- 
ing due  to  ascites  as  well  as  to  pregnancy. 

A  retraction  or  sinking-in  of  the  abdominal  walls  is  usually  asso- 
ciated with  the  appearances  of  great  emaciation  and  of  a  parchment- 
like  hardness  and  color  of  the  skin.  It  may  be  due  to  a  tuberculous 
enteritis  or  peritonitis,  a  basilar  meningitis  (usually  tuberculous),  or 
to  cancer,  principally  of  the  gastro-intestinal  tract  or  peritoneum. 

(3)  MOVEMENTS. — These  may  be  respiratory,  peristaltic  (gastric 
and  intestinal),  and  circulatory. 

Respiratory  abdominal  movements  are  naturally  less  marked  in 
women  than  in  men,  and  more  marked  in  infants  than  in  adults. 
Increased  respiratory  movements  are  compensatory  to  diseases  of  the 
upper  thorax  which  interfere  with  free  and  full  expansion.  Dimin- 
ish ed  movements  indicate  diseases  below  the  diaphragm  accompanied 
with  peritoneal  pain,  general  or  local,  distention  of  the  abdomen  by 
large  tumor,  etc.,  or  paralysis  of  the  diaphragm. 

Abnormal  peristaltic  movements  suggest  chronic  pyloric  or  intes- 
tinal obstruction  or  stenosis,  often  due  to  cancer.  However,  in  certain 
thin  persons  with  relaxed  abdominal  walls,  comparatively  healthy  but 
nervous,  one  may  not  infrequently  witness  slowly  undulating  ver- 
micular movements  passing  beneath  the  walls,  particularly  after  some 
such  surface  excitant  as  a  tapping  or  filliping  with  the  finger,  press- 
ing with  a  cold  hand,  or  brushing  lightly  with  the  end  of  a  towel 
wrung  out  of  cold  water. 

Visible  movements  in  the  left  upper  quadrant  are  presumably 
caused  by  dilation  of  the  stomach,  the  condition  pointing  to  obstruc- 
tion of  the  pylorus.  Waves  creeping  around  the  umbilical  region 
indicate  swollen  small  intestines,  with  the  obstruction  at  or  near  the 
ileo-cecal  valve;  those  following  a  circumferential  route  along  the 
colon,  and  in  a  reverse  direction  from  the  gastric  ones  (left  to  right), 
suggest  obstructive  disease  at  or  near  the  sigmoid  flexure. 

Vascular  movements  may  be  communicated  to  the  abdominal  wall 
directly  or  indirectly  by  the  aorta,  causing  epigastric  or  umbilical 
pulsations.  The  latter  are  often  seen  in  nervous,  tense,  thin  subjects, 
especially  women.  Or  they  may  point  to  aneurism,  or  to  a  carcinoma- 
tous  or  sarcomatous  growth  of  the  pylorus,  intestine,  or  mesenteric 
glands  overlying  the  aorta  and  transmitting  the  pulsations.  Vascular 
pulsation  of  the  liver  is  sometimes  visible  in  the  right  upper  quad- 


370  IMIYSICAL    DIAGNOSIS 

rant  synchronous  with  the  apex-beat,  and  associated  with  tricuspid 
insufficiency  due  to  various  causes. 

(4)  LOCAL  ABDOMINAL  ENLARGEMENTS. — These  are  very  impor- 
tant, although  more  amenable  to  palpation  than  to  inspection,  and 
will  be  more  fully  discussed  under  that  head.  Circumscribed  disten- 
tions  of  the  belly  may  occur  in  any  region ;  they  may  be  nodular  and 
the  size  of  a  nut,  or  as  large  and  irregular  in  outline  as  a  fist  or 
pumpkin;  they  may  be  fixed  or  movable,  according  as  they  may  be 
affected  by  respiration  and  posture;  they  may  appear  to  be  a  part 
of  or  attached  to  viscera,  or  independent  neoplasms,  or  inflammatory 
exudations.  Visible  enlargements  in  the  righ  t  upper  sextant  are  usu- 
ally hepatic  or  cholecystic,  and  movable  with  respiration;  rarely,  a 
movable  right  kidney  may  also  be  seen  to  cause  slight  bulging  of 
the  abdominal  wall.  In  the  middle  upper  sextant  the  most  common 
protrusions  are  due  to  pyloric  cancer;  less  common  are  pancreatic 
growths  and  aneurism.  In  the  left  upper  sextant  splenic,  gastric, 
and  colic  tumors  are  most  often  found.  Cecal  tumors  and  appen- 
diceal  abscesses,  as  well  as  ovarian  enlargements,  cause  local  swell- 
ings in  the  right  lower  sextant  most  frequently,  although  I  have 
seen  displaced  kidney  in  this  region  several  times.  The  causes  of 
visible  bulging  in  the  middle  lower  sextant  may  be  tumors  of  the 
small  bowel,  mesenteric  growths,  uterine  and  vesical  enlargements. 
In  the  left  lower  sextant,  sigmoid  tumors  and  fecal  impactions,  ova- 
rian and  omental  growths  appear. 

LOCAL  DEPRESSIONS  are  rare,  but  may  occur  in  the  right  or  middle 
lower  sextants  from  chronic  peritonitis  with  circumscribed  adhesions. 

PALPATION 

Knowledge  of  the  value  and  mode  of  palpation  alone  will  not 
suffice  for  a  certain  deficiency  in  knack,  which  cannot  be  described; 
but  a  good  basis  for  acquiring  skill  in  practising  this  method  of 
obtaining  and  interpreting  physical  signs  should  be  gotten  by  careful 
attention  to  a  few  leading  facts  and  guiding  principles. 

The  position  of  the  patient  is  of  first  importance,  the  object  being 
to  have  the  abdominal  muscles  as  relaxed  as  possible.  Hence,  the 
recumbent  posture,  with  the  head  and  shoulders  slightly  elevated, 
.sometimes  with  the  knees  drawn  up,  but  not  always,  as  many  patients 
relax  less  than  when  the  legs  are  extended,  and  their  elevation  may 
be  in  the  way  of  the  examiner's  arms,  or  throw  a  shadow  over  the 
exposed  abdomen  which  is  not  satisfactory,  as  the  eyes  work  with  the 


METHODS   OF   ABDOMINAL   EXAMINATION       371 

hands  during  manipulation.  Having  the  patient  breathe  quietly  with 
the  lips  slightly  parted  aids  in  softening  the  belly  walls  automatically 
and  psychically  by  diverting  his  attention.  In  nervous,  timid,  and 
ticklish  patients  it  is  often  necessary,  before  going  on  with  palpation, 
to  divert  the  mind  by  engaging  in  conversation,  feeling  the  pulse 
with  the  other  hand,  observing  the  tongue,  palpating  gently  elsewhere 
than  over  the  particular  region  of  purpose,  and  so  on.  In  urgent 
and  extreme  cases,  anesthesia  may  be  required. 

The  hand  of  the  examiner  should  be  warm,  so  as  to  avoid  reflex 
contraction  of  the  abdominal  muscles.  The  first  touch  should  be 
the  placing  of  the  whole  hand  upon  the  abdomen  with  light  pressure, 
and  then  gradually  passing  it  over  the  surface  with  circular  move- 
ments and  increasing  pressure  with  the  palmar  aspect  of  the  fingers, 
so  as  to  accustom  the  patient  to  the  palpation,  and  not  resist  the 
deeper  and  more  detailed  investigation  to  follow.  Poking  bruskly 
with  the  finger-tips  in  vertical  fashion  must  consistently  be  avoided 
if  the  examiner  wishes  to  retain  the  confidence  of  his  patient.  There- 
fore, also,  painful  and  tender  areas  should  be  ascertained  before  touch- 
ing, as  nearly  as  possible,  by  heeding  the  patient's  references,  so  that 
their  exact  location  may  be  determined  last,  otherwise  considerable 
tenseness  and  reflex  irritability  of  the  walls  may  ensue  to  restrict 
and  confuse  the  doctor.  Slightly  deeper  pressure  and  digital  grasp 
is  often  afforded  at  the  end  of  the  expiratory  movement  of  the  belly 
wall,  with  apparently  greater  natural  tolerance.  Sometimes,  when 
the  resistance  of  the  abdominal  wall  is  especially  marked,  two  hands 
may  be  employed,  one  on  top  of  the  other,  with  the  finger-tips  of 
the  superposed  hand  resting  back  of  the  nails  of  the  under  hand,  a 
reenforced  pressure  thus  being  maintained  during  several  respirations 
while  the  lower  hand  is  gaining  impressions  steadily.  This  method 
is  often  necessary  in  exploring  the  upper  middle  region  of  the  belly, 
because  of  the  contracted  recti  muscles  and  the  central  and  lateral 
tendinous  ridges  bounding  them  longitudinally.  Good  relaxation  may 
also  be  obtained  in  many  intractable  instances  of  abdominal  rigidity 
by  making  the  examination  while  the  patient  is  nearly  stretched  out 
in  a  tub  of  hot  water,  the  temperature  of  which  has  been  raised  grad- 
ually from  100°  to  about  110°  or  115°  F.,  the  patient  being  immersed 
meanwhile.  Further  special  points  in  palpation  will  be  mentioned 
in  connection  with  the  conditions  and  organs  to  which  they  are 
applicable. 

In  palpating  the  abdomen  we  seek  information  on  the  following : 
(1)  The  wall  itself;  (2)  general  enlargement  and  retraction;  (3) 


372  PHYSICAL    DIAGNOSIS 

local  bulgings  or  depressions  (rare) ;  (4)  pulsations,  and  movements 
due  to  respiration  and  peristalsis. 

(1)  The  Abdominal  Walls. — The  skin  may  be  smooth  and  feel 
doughy  or  putty-like,  particularly  at  the  sides  of  the  belly,  because 
of  edema.    The  proportion  of  fat  and  the  thickness  of  the  walls  may 
be  estimated  by  grasping  them  upward.     Relaxation  and  thinning  of 
the  walls  are  characteristic  after  pregnancy,  dropsy,  and  in  old  age 
and  during  the  progress  of  visceral  carcinoma.     The  bellies  of  the 
recti  muscles  may  manifest  a  general  rigidity  in  nervous  and  ticklish 
individuals,  in  tetanus,  muscular  rheumatism,  and  peritonitis.    Very 
often  a  local  contraction  of  abdominal  muscle  is  significant  of  local 
peritonitis,   of   appendicitis   especially  when   the  right   rectus   is   so 
affected.     These  so-called  muscular  tumors  differ  from  real  growths 
in  their  variable  resistance,  since  they  relax  and  harden  alternately, 
are  not  movable  as  most  intra-abdominal  tumors  are,  and  give  the 
impression  of  being  superficial. 

Other  palpable  irregularities  may  be  abscesses,  occasionally  of  tu- 
berculous origin ;  Jiernice,  epigastric,  umbilical ;  neoplasms,  such  as 
the  lipomas  or  soft  fatty  tumors,  or  sarcomas;  separation  of  the  rcdi 
muscles,  causing  a  soft  projection  in  the  median  line,  best  demon- 
strated in  bending  the  head  and  shoulders  forward  while  lying  on 
the  back;  thickening,  fixation,  and  retraction  of  the  umbilicus,  sug- 
gestive of  tuberculosis  or  cancer  of  the  peritoneum  or  liver.  The 
hernias  may  be  recognized  by  their  soft,  air-cushion  feel,  with  fine 
gurgling  sensation  on  pressure,  their  reducibility,  their  increased  ten- 
sion and  communicated  impulse  on  coughing,  and  the  tympanitic 
percussion  note.  Lipomas  are  soft,  but  feel  fleshy,  are  more  or  less 
movable  under  the  skin,  and  show  their  lobulated  structure  by  causing 
tiny  depressions  or  dimplings  in  the  overlying  skin  when  it  is  drawn 
firmly  over  the  tumor. 

(2)  General  Enlargement  of  the  Abdomen. — This  may  be  due  in 
the  first  place  to  an  EXCESS  OP  MURAL  OR  OMENTAL  FAT,  as  in  general 
obesity.    If  so,  the  enlargement  of  the  belly  is  then  found  to  be  pro- 
portionate to  the  bulkiness  of  the  extremities.     A  fat  abdominal  wall, 
however,  makes  it  always  difficult  to  palpate  and  discover  coexistent 
tumors  within  the  abdomen. 

The  intra-abdominal  physical  causes  of  general  enlargement  are 
principally  three:  an  excessive  quantity  of  gas  within  the  stomach 
and  bowels,  liquid  (usually  a  dropsical  transudate)  in  the  peritoneal 
sac,  or  a  very  large  abdominal  tumor. 

If  the  enlargement  is  due  to  ACCUMULATION  OF  GAS  within  the 


METHODS    OF    ABDOMINAL    EXAMINATION        373 

intestines,  producing  the  condition  known  as  meteorism  or  tympanites, 
the  abdomen  is  arched  like  a  barrel,  feels  tense,  although  slightly 
resilient,  and  is  accompanied  with  exaggerated  thoracic  and  impeded 
cardiac  action.  The  causes  of  moderate  distention  are  often  dietetic 
or  gastro-intestinal ;  in  children,  usually  due  to  the  too  free  feeding 
of  starchy  preparations,  and  in  adults  to  similar  and  sweet  and  fatty 
foods,  such  as  oatmeal,  hot  breads,  rich  soups,  fried  meats  and  pota- 
toes and  sweet  potatoes,  beans,  pastry,  bananas,  etc.  There  may  be 
a  congenital  dilation  of  the  colon  with  more  or  less  permanent  flatu- 
lence, or  the  dilation  may  be  due  to  intestinal  obstruction  low  down. 
I  once  saw  an  enormous  abdominal  enlargement  in  an  aged  minister, 
in  whom  the  rectal  tube  could  not  be  passed  more  than  six  or  eight 
inches,  and  where  the  autopsy  showed  great  distention  upward  and 
inward  of  the  sigmoid  loop,  which  was  kinked  and  twisted  (volvulus) 
at  the  pelvic  rim.  Typhoid  fever,  peritonitis,  and  hysteria  may  also 
give  rise  to  severe  gaseous  distention  of  the  bowel.  In  a  few  cases 
the  general  distention  may  be  caused  by  free  gas  in  the  peritoneal 
cavity,  the  result  of  a  perforated  gastric  or  intestinal  ulcer,  or  appen- 
dix, or  of  infection  from  the  gas-forming  bacillus.  In  such  instances 
the  lateral  liver  dulness  is  apt  to  disappear  when  the  patient  lies 
on  the  left  side,  the  gas  then  being  free  to  diffuse  between  the  liver 
and  the  ribs;  similarly  with  respect  to  the  splenic  dulness  when  the 
patient  lies  on  the  right  side. 

FLUID  DISTEXTION  of  the  peritoneum  is  proven  partly  by  the 
increased  sense  of  resistance  without  the  drumlike  resilience,  but 
mainly  by  the  detection  of  fluctuation.  This  is  elicited  by  applying 
one  hand — feeling  principally  with  the  finger-pulps — to  one  side  of 
the  belly,  while  the  other  side  is  tapped  gently  but  with  quick  impact 
by  the  palmar  surfaces  of  the  fingers  of  the  other  hand.  If  this  is 
done  near  the  supposed  level  of  the  fluid,  the  former  hand  receives 
the  impression  of  the  wave  propagated  by  the  percussion  tap  of  the 
latter.  Sometimes  the  lightest  touch  of  a  single  finger  suffices  to 
develop  fluctuation.  If  this  sign  is  not  demonstrable  in  the  flanks, 
one  may  find  it  lower  down  and  nearer  the  middle  line.  In  stout 
individuals,  who  are  at  the  same  time  apparently  ascitic,  the  wave 
may  actually  be  one  of  flabby  fat  simulating  the  liquid  one.  The 
possibility  of  error  may  be  eliminated  by  having  the  patient  or  an 
assistant  apply  the  ulnar  edge  of  the  hand  longitudinally  over  the 
linea  alba,  which  thus  cuts  off  the  superficial  wave.  The  liquid  fluc- 
tuation of  ascites  is  also  visible  in  its  travel  across  the  abdominal 
surface.  If  the  amount  of  fluid  in  doubtful,  undistended  cases  gives 


374  PHYSICAL    DIAGNOSIS 

rise  even  to  no  local  fluctuation  in  the  sitting  or  recumbent  postures, 
it  may  be  elicited  in  the  umbilical  region  while  the  patient  assumes 
the  knee-chest  position. 

The  causes  of  ascites  are  principally  cirrhosis  of  the  liver,  and  the 
later  stages  of  chronic  cardiac  dilation  from  valvular  lesions,  and 
renal  disease  with  general  dropsy.  Less  frequently  occurring  etiologic 
factors  are  interference  with  the  portal  circulation  by  a  thrombus  in 
the  portal  vein,  or  by  pressure  from  without,  as  an  abdominal  tumor ; 
interference  with  the  general  venous  circulation  by  pulmonary  em- 
physema (advanced),  and  chronic  tuberculous  and  cancerous  inflam- 
mation of  the  peritoneum. 

Solid  general  distention  of  the  abdomen  from  tumor  may  be  in- 
ferred palpably  by  the  firm,  unyielding  resistance  to  pressure,  the 
more  or  less  perceptible  irregularity  of  outline,  and  sometimes  bossel- 
lation  or  nodulation  of  surface,  more  marked  lateral  than  anterior 
projection  at  times,  and  the  absence  of  fluctuation. 

Among  the  most  common  organic  and  neoplastic  causes  of  general 
abdominal  distention  are  the  following:  great  enlargements  of  the 
liver  (cancerous,  amyloid,  leukemic,  malarial,  etc.) ;  spleen  (malarial, 
leukemic,  amyloid) ;  kidney  (sarcomatous,  cystic) ;  dilation  and  pro- 
lapse of  the  stomach  (gastrectasis,  gastroptosis) ;  ovarian  and  parova- 
rian  cystoma  and  uterine  fibroma;  retroperitoneal  and  peritoneal  lipo- 
mata  and  sarcomata ;  mesenteric  disease,  cancerous  especially.  Caution 
is  always  necessary  not  to  mistake  a  large  pregnancy  for  a  tumor 
of  pathologic  origin. 

General  retraction  of  the  abdomen  is  usually  accompanied  with 
marked  sensation  of  resistance,  thickness,  of  boardlike  hardness  some- 
times. I  have  found  it  characteristic  of  chronic  tuberculosis  of  the 
peritoneum  and  intestines;  somewhat  of  general  abdominal  carcino- 
sis,  with  a  sort  of  bogginess  to  the  touch;  and  also  of  chronic  lead- 
poisoning  with  colic;  in  children  with  tuberculous  meningitis,  and 
in  omental  interstitial  or  cancerous  thickening,  particularly  resistant 
in  the  upper  half  of  the  belly,  and  the  mass  not  movable  with  respi- 
ration. 

(3)  Local  Enlargements. — The  detection  of  these  is  of  the  first 
importance  in  the  palpation  of  the  abdomen.  The  following  points 
should  be  noticed:  Location  as  to  surface  and  region,  size,  contour, 
mobility,  consistency,  relationship  to  adjacent  structures  and  organs, 
the  presence  of  pulsation  or  crepitation,  and  tenderness.  These  fea- 
tures of  local  swellings  are  recognizable  only  by  careful  attention  to 
and  practise  in  the  details  of  technic.  It  is  considered  best  here  to 


METHODS    OF    ABDOMINAL    EXAMINATION        375 

indicate  the  main  characteristics  of  the  local  swellings  likely  to  be  met 
with  by  classifying  them  regionally. 

EPIGASTRIC  REGION,  OR  MIDDLE  UPPER  SEXTANT. — Here  as  else- 
where it  must  be  determined  first  whether  the  tumor  is  in  the  abdom- 
inal wall  or  in  the  abdominal  cavity;  and  also  whether,  if  in  the 
abdominal  wall,  it  is  really  a  growth  or  simply  a  localized  spasmodic 
contraction  of  a  belly  of  the  rectus  muscle.  If  the  latter,  gradual 
relaxation  with  continued  moderate  pressure  may  be  felt,  and  repeated 
and  exaggerated  contraction  may  be  elicited  by  flicking  the  overlying 
.skin,  or  by  having  the  patient  attempt  to  lift  the  head  and  shoulders 
from  the  dorsal  position. 

If  the  bulging  is  really  a  tumor  in  the  wall  of  the  abdomen,  both 
may  be  partially  or  completely  grasped  and  lifted,  whereas  an  intra- 
abdominal  tumor  slips  from  under  the  seizure  of  the  abdominal  wall, 
and  eludes  the  palpating  fingers  more  readily  than  when  the  wall  is 
not  so  manipulated.  Mural  swellings  in  this  region  may  be  abscesses 
or  fatty  growths. 

Distention  of  the  stomach  from  food  or  gas,  or  from  perma- 
nent dilation  xlue  to  cicatricial  (healed  gastric  ulcer)  or  cancerous 
stenosis  of  the  pylorus,  may  be  noted  here,  although  the  latter 
condition  is  more  commonly  palpable  lower  down  and  more  to 
the  left.  A  large  parietal  cancer,  such  as  the  colloid  variety,  may 
also  be  felt  in  this  region  as  a  diffuse,  firm  mass;  likewise  a  pyloric 
tumor. 

Pancreatic  cyst  and  cancer  may  be  felt  by  deep  palpation. 

Liver  enlargements,  such  as  cancer  nodules,  hydatid  cysts,  abscess, 
gumma,  and  downward  displacement  of  the  left  lobe,  occur  here. 
They  are  superficial  and  move  with  respiration. 

Aortic  aneurism  is  told  by  its  round,  firm  outline  and  expansile 
pulsation. 

The  transverse  colon  may  exhibit  distention  (soft,  doughy  sensa- 
tion) or  tumor. 

The  gall-bladder  may  be  distended  with  pus  or  calculi  (right  side 
of  epigastric  region) ;  if  the  latter,  some  crepitus  may  be  felt. 

The  lesser  peritoneal  cavity  may  contain  an  effusion. 

There  may  be  enlarged  mesenteric  or  retroperitoneal  glands,  from 
tuberculous,  cancerous,  or  Hodgkin's  disease.  In  these  cases  not  in- 
frequently aortic  pulsation  may  be  transmitted. 

HEPATIC  REGION,  OR  RIGHT  UPPER  SEXTANT. — Liver  enlarge- 
ments of  all  forms  are  palpable  here ;  for  example,  passive  congestion, 
fatty,  amyloid,  malarial,  cancerous,  leukemic,  syphilitic  liver,  hydatid 


376  .PHYSICAL    DIAGNOSIS 

disease,  hypertrophic  cirrhosis  (biliary,  or  the  first  stage  of  the 
atrophic  form),  and  abscess. 

Distended  gall-bladder  may  be  due  to  hydrops,  pus,  concretions, 
cancer.  The  viscus  is  often  pear-shaped,  and  may  be  swung  in  a 
short  arc  of  circle  whose  radius  is  the  length  of  the  enlarged  organ. 

Sub  diaphragmatic  abscess  may  be  the  cause  of  a  boggy  bulging. 
A  perinephric  abscess  likewise. 

The  hepatic  flexure  and  adjacent  portions  of  the  ascending  and 
transverse  colon  may  be  the  seat  of  cancer  or  fecal  impactions. 

Movable  kidney  and  renal  enlargements  palpable  here  may  be 
hydronephrosis,  pyonephrosis,  sarcoma,  cystic  growth,  rarely  cancer 
of  the  suprarenals,  or  hypernephroma. 

APPENDICEAL  REGION,  OR  RIGHT  LOWER  SEXTANT. — In  this  very 
important  area  of  modern  medical  and  surgical  attention,  in  the  first 
place,  conditions  in  the  belly  wall  must  be  studied.  Thus,  psoas 
abscess  due  to  tuberculous  caries  of  the  vertebrae  may  point  here 
low  down.  Inguinal  hernia  is  also  of  common  occurrence. 

Pericecal  or  pcriappendiceal  abscess  may  be  felt  after  the  first  two 
or  three  days  of  a  severe  acute  appendicitis.  There  is  an  indistinct 
resistant  sense  of  fluctuation.  Chronic  appendicitis  may  be  palpated 
as  a  small,  sausage-shaped  tumor,  or  in  those  with  thin,  relaxed 
belly  walls,  as  a  cordlike  thickening. 

Fecal  impaction  in  the  cecuin,  with  or  without  typhlitis,  peri- 
typhlitis,  or  abscess,  may  be  palpable  here  as  a  rounded,  uneven, 
doughy,  firm  mass,  with  or  without  tenderness  and  external  swelling. 
Enteroliths  may  also  occur. 

Cancer  of  the  cecum  and  ascending  colon  causes  a  hard,  irregular 
lump. 

Intussusception  is  found  more  often  in  children  as  a  firm  tumor 
with  the  caliber  of  the  bowel,  associated  with  a  straining  to  defecate. 
The  tumor  is  usually  felt  nearer  the  navel  than  the  other  swellings 
of  this  region. 

Retro  peritoneal  sarcoma-  may  project  in  this  area  as  a  large  mass. 

Floating  kidney  is  not  at  all  infrequently  palpable  here. 

The  following  pelvic  enlargements  may  be  palpable  in  this  region : 
ovarian  tumor;  tubal  swellings,  as  pus  tubes  of  large  size;  pelvic 
abscess;  extra-uterine  pregnancy;  pelvic  hematocele.  Tumors  of  the 
right  ovary  are  usually  firm  when  small  and  barely  palpable.  As 
they  increase  in  size  they  may  become  somewhat  elastic  in  feel,  and 
since  they  are  often  cystic  fluctuation  may  be  elicited.  The  enlarge- 
ments are  nearer  the  median  line  than  those  of  appendiceal  or  typh- 


METHODS    OF    ABDOMIXAL    EXAMIXATIOX        377 

litic  origin.  The  other  pelvic  swellings  also  occur  in  the  lower  half 
of  this  region,  nearer  the  median  line  than  the  perityphlitic  tumors. 

PELVIC  OR  PUBIC  REGION,  OR  LOWER  MIDDLE  SEXTANT. — Swell- 
ings here  may  be  due  to  distended  bladder,  fibroid  or  pregnant  uterus, 
tuberculous  peritonitis,  and  the  pelvic  enlargements  mentioned  in  the 
previous  paragraph.  A  long  and  inflamed  appendix  may  sometimes 
be  found  in  the  right  side  of  the  pelvic  region,  and  this  area  may 
project  as  a  part  of  a  diffuse,  baggy  bulging  of  the  lower  zone  of  the 
abdomen  from  dilation  of  the  stomach  and  gastroptosis. 

SIGMOID  REGION,  OR  LEFT  LOWER  SEXTAXT. — Xear  Poupart's 
ligament  one  may  palpate  hernia,  enlarged  glands  (syphilis,  cancer, 
Hodgkin's  disease),  and  psoas  abscess.  Carcinoma  of  the  sigmoid 
flexure,  hard  fecal  accumulations,  and  perisigmoidal  abscess  may  all 
be  palpable  here.  Volvulus,  and  rarely  a  displaced  kidney  or  spleen, 
may  occur.  In  women,  near  the  inner  portion  of  this  area  the  ovarian 
tumors,  broad-ligament  cysts,  hematomas,  and  intussusceptions  may 
be  met  with. 

SPLENIC  REGION,  OR  LEFT  UPPER  SEXTANT. — One  may  feel  here 
an  enlarged  or  dislocated  spleen;  a  mobile  kidney;  a  gastric  cancer  or 
dilated  stomach  ;  renal  tumors,  as  cystic  kidney  and  perinephric  ab- 
scess; local  peritoneal  effusions;  and  enteroliths  or  impacted  feces 
in  the  splenic  flexure  of  the  colon. 

I'.MBiLiCAL,  OR  CENTRAL  REGION. — Umbilical  hernia  is  frequently 
perceived  here,  especially  in  young  children.  It  is  soft,  and  often 
feels  like  a  little  air-bladder  with  tissue-paper  walls,  which  presses 
out  against  the  finger  with  coughing  and  crying.  A  hard,  cordlike 
adhesion,  tender  to  the  touch,  and  usually  associated  with  colicky 
attacks,  is  too  often  overlooked.  The  attachment  may  be  a  fetal 
remnant  or  an  omental  adhesion. 

Also  palpable  here  may  be  the  following:  dilated  stomach,  large 
pyloric  cancer,  which  has  dragged  the  stomach  downward;  floating 
kidney,  spleen,  or  liver;  prolapse  and  tumor  of  the  colon;  the  soft, 
pendent  bulging  of  general  enteroptosis ;  the  hard,  nodular,  or  lumpy 
mass  of  retroperitoneal  sarcoma;  enlarged  mesenteric  glands  (cancer 
or  tuberculosis) ;  shrinking  and  thickening  of  the  omentum  from 
chronic  peritonitis,  cancerous  or  tuberculous  growths;  hydatid  liver 
disease  or  tumor  of  the  gall-bladder;  and  the  expansile  pulsations 
of  saccular  or  spindle-shaped  aortic  aneurism. 

(4)  Pulsations  and  Respiratory  and  Peristaltic  Movements. — The 
PULSATIONS  OF  THE  AORTA  have  already  been  pointed  out  in  connec- 
tion with  palpable  aneurism  in  the  regions  (epigastric  and  umbilical) 


378  PHYSICAL   DIAGNOSIS 

in  \vhich  it  may  occur.  It  is  not  uncommon,  also,  to  palpate  a  marked 
aortic  pulsation  along  the  whole  of  its  abdominal  course  in  two  classes 
of  patients,  namely,  thin  young  women  of  neurotic  and  hysteric  type, 
sometimes  of  the  relaxed,  tuberculous  type,  and  those  advanced  in 
years,  men  and  women,  having  tense,  sclerotic  aorta?. 

The  RESPIRATORY  MOVEMENTS  of  the  abdominal  walls  are  exag- 
gerated and  jerky  in  nervous  conditions,  which  may  be  temporary  and 
disappear  with  diverting  conversation  and  suggestion;  they  are  dimin- 
ished in  painful  diseases  of  the  peritoneum  of  general  or  local  char- 
acter and  origin,  in  lead-colic,  large  tumor  masses,  etc. 

The  slow  VERMICULAR  MOVEMENTS  of  peristalsis  are  seldom  felt 
as  easily  as  they  are  seen.  They  signify  some  chronic  obstruction  of 
the  pylorus  usually  when  in  the  upper  zone  of  the  abdomen,  or  a 
similar  condition,  as  cancer  of  the  intestine,  when  in  the  middle  or 
lower  zones. 

PERCUSSION 

The  technic  of  abdominal  percussion  does  not  differ  from  that  of 
thoracic  except  that,  as  a  rule,  very  light  strokes  are  advisable  to 
prevent  overlooking  small  areas  of  dulness  because  of  the  ease  with 
which  adjacent  tympany  may  be  elicited. 

The   NORMAL,   GENERAL   ABDOMINAL   NOTE  is,   of   COUTSe,   TYMl'AN'- 

ITIC.  It  varies,  however,  as  to  pitch  and  intensity,  as  well  as  clearness, 
in  different  regions,  according  to  the  underlying  volume  of  viscus 
percussed,  and  its  degree  of  emptiness  of  liquid  or  solid  material. 
Thus,  over  the  small  intestines,  around  the  umbilical  area,  the  tyni- 
panicity  is  higher  pitched  and  not  as  loud  and  clear  as  over  the  colon, 
nor  over  the  latter  as  compared  with  the  empty  stomach.  The  degree 
of  tension,  also,  affects  the  tympanitic  sound — the  greater  the  tension 
the  higher  the  pitch;  therefore,  it  is  often  difficult  to  differentiate 
stomach,  large  and  small  bowel  by  percussion  near  their  anatomic 
borders,  because  of  the  numerous  variations  in  size  and  tension  which 
may  affect  one  or  more  portions  of  the  alimentary  tract. 

In  the  upper  part  of  the  epigastrium  (middle  upper  sextant), 
owing  to  the  presence  of  the  left  lobe  of  the  liver,  light  percussion 
demonstrates  slight  dulness. 

EXAGGERATED  TYMPANITIC  SOUND  over  the  abdomen  generally  i* 
associated  with  gaseous  distention  of  the  bowel,  as  in  peritonitis  and 
typhoid  fever,  or  with  enormous  dilation  and  prolapse  of  the  stomach. 
or  with  gas  in  the  peritoneal  cavity  from  a  ruptured  ulcer  (typhoid, 
tuberculous,  cancerous,  gastric). 


METHODS    OF    ABDOMINAL    EXAMINATION        379 


FIG.  78. — SHOWING  THE  CENTRAL,  TYMPANICITY 
AND  LATERAL  DULNESS  OF  AN  ABDOMEN  CON- 
TAINING FREE  FLUID.  (Butler.) 


ASCITES. — The  commonest  cause  of  more  or  less  generalized  dul- 
ness  on  percussion  of  the  belly  is  fluid,  usually  dropsical,  in  the  peri- 
toneal sac.  The  loca- 
tion, size,  and  outline  of 
the  dulness  depends,  ob- 
viously, upon  the  quan- 
tity of  the  fluid  present, 
and.  since  it  gravitates 
to  the  lowest  portions, 
upon  the  position  of  the 
patient.  Hence,  when 
the  dorsal  decubitus  is 
assumed,  dulness  is  elic- 
ited in  the_ flanks  if  the 
effusion  is  sufficient  to 
rise  above  the  level  of  the  heavy  lateral  muscles,  and  over  a  narrow 
zone  at  the  lower  part  of  the  belly.  The  middle  part  gives  tympanitic 

sound  due  to  the  floated 
bowels.  In  certain  large 
individuals  with  large- 
caliber  ed  bowels  and  but 
moderate  amount  of  liq- 
uid, although  slight  bulg- 
ing in  the  flanks  may  be 
visible  and  local  fluctua- 
tion be  palpable,  tym- 
pany  instead  of  dulness 
may  be  demonstrable 
here  nevertheless.  AVhen 
the  patient  lies  upon 
either  side,  tympanitic  sound  is  elicited  over  the  flank  of  the  upper 
side  where  in  the  recumbent  posture  dulness  was  found.  In  the  stand- 
ing position  the  dulness  is  confined  principally  to  the  lower  half  of 
the  abdomen,  in  the  median  and  parasternal  lines  reaching  upward 
to  the  level  of  the  navel,  but  seldom  higher. 


FIG.  79. — SHOWING  CENTRAL  DULNESS  AND  LAT- 
ERAL TYMPANICITY  OF  ABDOMINAL  CYSTIC  OR 
SOLID  TUMORS.  (Butler.) 


AUSCULTATION 


Auscultation  of  the  abdomen  in  general  practically  gives  no  in- 
"V^ormation  of  any  decided  value.  Any  significance  attaching  to  the 
^\  sounds  produced  in  the  gastro-intestinal  tract,  and  both  the  liver 


380  PHYSICAL    DIAGNOSIS 

and  spleen,  will  be  narrated  briefly  in  referring  to  these  organs 
specifically. 

In  regard  to  the  peritoneum,  FRICTION  SOUNDS  or  a  soft,  rustling 
CREPITUS  may  be  heard  whenever  a  plastic  inflammatory  exudate  of 
extensive  nature  involves  its  surface  where  the  respiratory  movements 
may  be  communicated;  hence  is  more  often  heard  over  the  liver  and 
spleen,  as  a  perihepatitis  or  perisplenitis,  or  a  subphrenic  peritonitis. 
Creaking  and  crumpling  sounds  are  sometimes  audible  in  cases  of 
old,  adhesive  peritonitis,  often  of  pelvic  origin,  or  fine  crackles  may 
be  heard  over  the  cecum  in  perityphlitis. 

VASCULAR  SOUNDS  occur,  such  as  the  bruit  of  aortic  aneurism 
(systolic),  pressure  murmurs  (also  systolic)  due  to  growths  encroach- 
ing upon  the  aorta,  and  the  hemic  murmurs  of  marked,  as  pernicious, 
anemia.  A  systolic  bruit  in  the  epigastric  region  has  been  observed, 
associated  with  expansile  pulsation,  in  which  the  cause  was  undoubt- 
edly a  distended,  displaced  gall-bladder. 


SECTION    VI 

THE   PRINCIPAL   SPECIAL   ORGANS  OP   THE 

ABDOMEN 


CHAPTER    XVII 
THE  STOMACH  AND  INTESTINES 

TOPOGRAPHIC  ANATOMY  OF  THE  STOMACH 

THE  stomach,  pear-  or  flask-shaped,  slopes  a  little  obliquely  down- 
ward from  its  larger  (cardiac)  or  left  end  to  the  right  or  pyloric 
end,  so  that  about  five-sixths  of  the  organ  lies  to  the  left  of  the 
median  line  of  the  body.  The  upper  limit  of  the  fundus,  where  it 
fits  into  the  dome  of  the  diaphragm,  reaches  to  the  fifth  rib  in  the 
nipple-line,  behind  the  apex  of  the  heart.  The  fundus  is  adjacent 
to  the  spleen  and  left  kidney,  and  is  partly  overlapped  in  front  by  the 
lower  border  of  the  left  lung,  the  heart,  and  the  left  lobe  of  the  liver. 

The  cardiac  orifice  lies  back,  or  possibly  £  to  1  in.  to  the  left,  of 
the  sternal  junction  of  the  seventh  costal  cartilage.  It  is  at  least 
4  in.  from  the  anterior  surface  of  the  body. 

The  lesser  curvature  bows  downward  in  passing  to  the  right  from 
the  cardiac,  then  ascends  with  a  short  curve  to  the  pylorus.  It  also 
lies  deeply,  and  is  adjacent  to  the  pancreas,  above  and  behind. 

The  pyloric  orifice  is  more  superficial  than  the  cardiac  orifice,  and 
also  more  movable.  It  lies  in  or  slightly  to  the  right  of  the  middle, 
or  even  the  right  sternal  line,  from  1  to  2  in.  below  the  tip  of  the 
ensiform  cartilage.  It  is  directly  behind  the  liver. 

The  greater  curvature  has  a  gentle  convexity  downward  and  for- 
ward, connecting  the  pylorus  with  the  fundus,  and  reaches  the  level 
of  the  infracostal  line  (connecting  the  tips  of  the  tenth  ribs).  When 
the  normal  stomach  is  considerably  distended,  the  greater  curvature 
may  reach  as  far  as  the  navel.  It  is  adjacent  to  the  transverse  colon 
below. 

381 


382  PHYSICAL   DIAGNOSIS 

Thus  the  stomach  occupies  in  part  the  left  inframammary,  the 
left  hypochondriac  region  or  left  upper  sextant,  and  the  epigastric 
region  or  middle  upper  sextant.  That  portion  of  the  stomach  which 
may  be  palpable  forms  a  spherical  triangular  area  bounded  below  by 
the  greater  curvature,  to  the  right  by  the  lower  border  of  the  liver, 
and  to  the  left  by  the  lower  border  of  the  costal  cartilages. 

The  so-called  Traube's  semilunar  space  is  the  area  of  the  lower 
ribs  which  are  in  contact  with  or  cover  the  parietal  surface  of  the 
stomach.  It  is  bounded  by  the  liver  and  lung  above,  the  spleen  to  UK- 
left,  and  the  liver  also  (left  lobe)  to  the  right.  Over  this  region 
the  true  gastric  tympanitic  sound  is  elicited. 

PHYSICAL    EXAMINATION    OF   THE    STOMACH 

INSPECTION 

The  normal  stomach  has  no  visible  signs. 

Concerning  the  pathologic  stomach,  we  aim  to  determine  its 
(a)  position;  (b)  size;  (c)  movements:,  (d)  tumors. 

Displacement  and  distention  of  the  stomach  may  be  considered 
together,  as  they  are  often  associated  conditions;  a  dilated  (gastrec- 
tasis)  stomach  is  usually  at  the  same  time  prolapsed,  especially  if  due 
to  organic  stricture  of  the  pylorus;  on  the  other  hand,  however,  a 
prolapsed  stomach  (gastroptosis)  may  occur  with  such  slight  or  mod- 
erate atonic  dilation  as  not  to  be  discoverable  by  physical  examination. 
These  cases  may  be  indicated  by  more  or  less  diffuse  bulging  in  either 
of  the  left  sextants,  or  in  the  umbilical  region.  The  lower  curvature 
may  even  be  seen  as  a  transverse  shadow  or  line  moving  in  the  hypo- 
gastric  or  pelvic  region  with  inspiration.  The  epigastric  region,  on 
the  contrary,  is  relatively  depressed.  Of  course,  these  signs  are  visible 
only  in  those  individuals  having  comparatively  thin  abdominal  walls. 
In  marked  gastroptosis  a  groove  may  be  seen  extending  from  the 
navel  to  the  ribs  which  represents  the  lesser  curvature  of  the  stomach. 
These  phenomena  may  all  be  better  visible  with  the  patient  in  the 
semi  recumbent  position,  and  the  abdomen  viewed  from  behind  while 
the  light  falls  directly  upon  it,  although  it  should  be  carefully  ob- 
served from  in  front  and  at  various  side  angles  as  well. 

The  respiratory  movements  of  the  lower  curvature  of  the  stomach 
are  generally  seen  only  when  the  stomach  is  tensely  dilated,  either 
from  the  gas  of  fermentation  or  of  artificial  distention  (see  under 
Percussion).  Peristaltic  movements  are  also  better  visible  under  like 
conditions  of  the  gastric  walls.  They  may  be  seen  to  pass  as  slow 


THE    STOMACH    AND    INTESTIXES  383 

waves  from  left  to  right,  sometimes  excitable  by  finger-tapping;  if 
the  pylorus  is  low  down  because  of  a  weighty  cancerous  growth  there, 
the  waves  show  a  distinctly  downward  course  as  well.  Benign  stenosis 
of  the  pylorus  from  cicatrices  of  healed  gastric  ulcer,  adhesions,  and 
simple  thickening,  may  likewise  be  signified  by  the  detection  of  peri- 
staltic gastric  waves. 

Tumors  of  the  stomach  are  not  visible  unless  large,  as  in  advanced 
cases  of  scirrhous  cancer  of  the  pylorus  in  emaciated  persons,  where 
the  growth  may  appear  well  below  the  left  lobe  of  the  liver.  Such 
neoplasms  are  not  subject  to  respiratory  mobility — a  differential  point 
in  relation  to  tumors  of  the  liver  and  gall-bladder. 

PALPATION 

Palpation  of  the  stomach  determines  with  fuller  results  the  visible 
indications.  The  normal  stomach  cannot  be  palpated  unless,  in  indi- 
vidual cases,  it  is  greatly  distended  with  a  heavy  meal,  or  from  gas. 
Slight  epigastric  tenderness  on  pressure  is  common  to  most  normal 
persons. 

Tenderness  is  abnormally  increased  in  palpating  the  stomach 
affected  with  acute  or  chronic  inflammation  (gastritis),  when  it  is 
rather  diffuse;  in  gastric  ulcer,  when  it  is  sharply  localized;  and  in 
cancer,  when  it  is  indefinite  or  circumscribed  to  the  tumor  area. 

Displacement  and  dilation  of  the  stomach  cannot  be  palpated  by 
its  boundaries,  except  in  rare  instances  in  which  the  greater  curvature 
may  be  felt  assisted  by  the  guiding  of  vision.  The  dilated  stomach 
gives  a  soft,  baggy  feel  below  the  borders  of  the  left  ribs,  often  as 
far  as  the  umbilicus.  A  splashing  or  succussion  sensation  may  be 
elicited  when  gas  and  liquid  are  present. 

Increased  resistance  of  the  gastric  walls  means  hypertrophic  thick- 
ening of  the  muscular  coat,  which  is  usually  associated  with  general 
distention  of  the  organ.  Firm  and  moderately  diffuse  resistance  just 
below  the  rib  borders  may  signify  a  large  colloid  cancer  of  the  stomach 
walls.  This  must  not  be  confounded  with  a  tense  belly  of  the  left 
rectus  muscle. 

Peristaltic  waves  which  can  be  felt  as  well  as  seen  are  important 
because  of  their  indication  of  hypertrophic  dilation  of  the  stomach, 
secondary  to  some  pyloric  obstruction,  and  often  giving  a  fair  indi- 
cation of  the  size  of  the  stomach.  Usually  the  waves  undulate  from 
left  to  right,  but  in  certain  extreme  cases  of  stenosis  they  are  reversed 
(or  antiperistalsis) .  Kussmaul  describes  in  the  phrase  "peristaltic 
27 


384  PHYSICAL    DIAGNOSIS 

unrest,"  a  palpable  peristalsis  in  neurotic  individuals  without  gastric 
dilation. 

Tumors  of  the  stomach,  especially  the  pylorus,  cannot  be  felt 
unless  the  latter  is  pushed  down  and  sufficiently  parietal.  Carcinoma 
is  generally  found  as  a  dense,  irregular  mass,  a  little  to  the  right 
of  the  median  line,  between  the  xiphoid  and  the  navel,  although  in 
a  few  instances  I  have  palpated  it  a  little  below  the  latter  point.  The 
cancer  may  be  slightly  movable  with  respiration,  especially  when 
bound  to  the  liver  by  adhesions,  and  when  low  down  is  quite  movable 
with  the  hand,  and  with  change  of  posture.  A  diffuse  thickening 
of  the  stomach  wall  in  the  left  parasternal  line  just  below  the  borders 
of  the  ribs  may  be  due  to  a  perigastric  deposit  as  a  consequence  of  a 
perforating  gastric  ulcer.  Sometimes  a  pancreatic  growth  may  be 
mistaken  for  a  gastric  cancer,  and  vice  versa. 

PERCUSSION 

Percussion  of  the  stomach  must  be  done  with  the  greatest  care  in 
technic,  otherwise  one  may  be  easily  misled  both  by  intragastric  and 
adjacent  conditions.  Normally,  gastric  tympany  is  limited  to  Traube's 
half-moon-shaped  space,  where  it  is  parietal,  although  a  modified  or 
relative  gastric  tympany  may  be  elicited  beyond  these  borders.  Gentle 
percussion  suffices  to  discover  it.  The  tympany  is  frequently  high 
in  pitch,  although  lower  than  that  obtained  over  the  intestines,  gen- 
erally ;  nevertheless,  the  tympany  over  the  colon  adjacent  to  the  stom- 
ach is  often  indistinguishable  from  that  over  the  latter,  indeed,  some- 
times because  the  colon  is  so  distended  as  to  overlap  the  stomach. 
In  order  to  separate  gastric  from  colonic  tympany  it  may  be  necessary 
to  distend  the  stomach  by  the  same  means  usually  employed  to  ascer- 
tain its  size  in  suspected  cases  of  dilation  (see  below).  Under  other 
circumstances  the  amount  of  gastric  tympany  obtainable  will  depend 
greatly  upon  the  condition  of  the  gastric  contents — the  presence  and 
relative  quantities  of  gas  and  liquid  or  solid  matter;  upon  the  extent 
of  overlapping  lung  and  liver,  either  of  which  may  be  enlarged,  and 
upon  pleural  effusion  or  splenic  tumor. 

•Therefore,  while  the  upper  border  of  the  stomach  lies  about  on 
a  level  with  the  fifth  to  the  sixth  rib  in  the  parasternal  and  nipple 
lines,  and  at  the  seventh  or  eighth  rib  in  the  anterior  axillary  line, 
one  must  really  be  content  with  defining  the  lung-stomach  and  the 
lung-liver  boundaries,  by  noting  in  the  first  instance  where  tympanitic 
resonance  (with  light  percussion  stroke)  ends  and  tympanitic  clear- 


THE    STOMACH    AND    INTESTINES  385 

ness  begins,  and  in  the  second,  where  clearness  passes  into  tympanitic 
dulness  or  muffled  tympany. 

The  outer  or  left  limit  of  gastric  tympany  is  determined  by  per- 
cussing to  the  left  until  splenic  dulness  is  noticed  near  the  lower 
borders  of  the  ribs  in  the  axillary  lines. 

The  position  of  the  lower  border  or  greater  curvature  is  most 
surely  and  accurately  determined  by  artificially  distending  the  stomach 
either  with  gas  or  water,  preferably  the  latter,  sometimes  both;  in  any 
case,  the  object  being  to  separate  gastric  from  colonic  tympany,  the 
differences  in  pitch  being  usually  so  slight.  Ziemssen's  method  con- 
sists in  inflating  the  stomach  with  carbonic-acid  gas,  by  giving  the 
patient  a  heaping  teaspoonful  of  sodium  bicarbonate,  dissolved  in 
water,  followed  immediately  afterward  by  a  similar  solution  of  tartaric 
acid.  //  the  evolution  of  gas  is  sufficient  to  distend  the  stomach  to 
its  full  size,  but  not  so  violent  and  abundant  as  to  cause  a  sense  of 
oppression  or  collapse  from  cardiac  embarrassment,  then  this  proce- 
dure may  be  deemed  successful;  but  as,  after  the  administration  of 
these  substances,  the  quantitative  chemical  result  is  beyond  our  con- 
trol, the  method  is  too  uncertain  and  variable,  and  may  be  dangerous. 

Therefore,  a  better  method  of  distention,  and  a  safer,  is  to  pump 
air  through  a  stomach  tube,  introduced  previously,  to  which  is  at- 
tached an  ordinary  hand-bulb  syringe ;  discomfort  may  be  relieved  at 
once  by  allowing  the  air  to  escape.  The  air  should  be  forced  into  the 
stomach  at  first  quickly  and  vigorously,  so  as  to  cause  reflex  closure 
of  the  pylorus,  and  thus  prevent  distention  of  the  bowel.  By  this 
means  the  stomach  may  be  outlined  by  inspection  and  palpation,  as 
well  as  by  percussion  of  the  area  of  gastric  tympany. 

Still  another  method  of  determining  the  size  and  position  of  the 
stomach  by  its  greater  curvature  is  first  to  note  a  general  tympany 
below  the  left  ribs,  in  which  gastric  tympany  is  inseparable  from  the 
colonic,  and  then,  while  the  patient  is  standing,  have  him  drink 
freely  of  water,  after  which  percussion  will  develop  dulness  over  a 
zone  representative,  of  course,  of  the  lower  limits  of  the  stomach  or 
region  to  which  the  water  has  naturally  gravitated. 

Auscultatory  percussion  is  decidedly  more  accurate  and  satisfac- 
tory than  simple  percussion  for  outlining  the  area  of  gastric  tym- 
pany, by  determining  the  adjacent  lung,  liver,  spleen,  and  colon 
borders,  whether  the  stomach  be  normal  in  size  and  distention,  or 
inflated,  or  partially  filled  with  liquid.  Concerning  the  last-named 
test,  it  is  well  to  note  the  results  after  changes  of  posture,  the  patient 
having  previously  drunk  one  or  two  tumblerfuls  of  water.  The  dul- 


386 


PHYSICAL    DIAGNOSIS 


ness  obtained  while  the  patient  is  erect,  where  before  tympany  was 
elicited,  indicates  that  the  latter  is  gastric  and  not  colonic ;  and  when 

the  patient  is  then  placed 
in  the  recumbent  posi- 
tion, tympany  replacing 
the  water  dulness  again 
points  to  its  gastric  ori- 
gin, thus  determining, 
by  the  location  and  lim- 
its of  such  signs,  the 
position  and  extent  of 
the  stomach  area. 

In  the  technic  of 
FIG.  80. — To  DETERMINE  THE  OUTLINE  OF  THE  STOM-  auscultatory  percussion, 
ACH  BY  AUSCULTATORY  PERCUSSION  Thestetho-  a  mere  fillip  or  glancing 
scope  may  be  placed  at  either  of  the  points  indi- 
cated by  the  circles  during  the  first  percussion,  stroke  of  the  finger  is 
During  the  repercussion  it  should  be  shifted  to  a^  that  is  nCCCSSarv  in 
the  other  point.  Arrows  show  lines  along  which  ,  . 

percussion  should  be  conducted.    (Butler.)  approaching  the  borders 

of  the  viscus,  while  the 

chest-piece  of  the   stethoscope  is   held   over  the  body  or  near  the 
pylorus  of  the  organ.    The  in- 
dividual quality  and  pitch  of 
the  gastric  note  is  perceived 
first    by    listening    near 
the    angle    between    the 
ensiform    appendix    and 
the   left    costal    margin. 
Stroking    percussion    is    then 
practised  from   all   sides    to- 
ward the  stomach  area  until 
this  same  note  is  successively 
observed,    which    thus    deter- 
mines the  boundaries  of  the 
stomach. 

Tumors  of  the  stomach 
may  also  be  discovered  by 
this  method. 

Enlargement  of  the   area 
of    gastric    tympany   is    seen 
in  cases  of  dilation  and  downward  displacement,  as  from  pyloric 
tumor;    extrinsically,    because    of    cirrhotic    atrophy    of    the    liver, 


FIG.  81. — SHOWING  THE  METHOD  OF  DETER- 
MINING, BY  AUSCULTATORY  PERCUSSION, 
THAT  A  TUMOR  BELONGS  TO  THE  STOM- 
ACH RATHER  THAN  TO  THE  LIVER  OR  IN- 
TESTINE. If  the  tumor  involves  the  wall 
of  the  stomach  the  percussion  notes  over 
points  A,  B,  C,  and  D  differ,  but  C  resem- 
bles D  much  more  nearly  than  A  or  B  re- 
semble D.  (Butler.) 


THE    STOMACH    AND    INTESTINES  387 

retraction  of  the  left  lung  from  fibroid  phthisis,  frequent  preg- 
nancies, etc. 

The  percussion-area  is  diminished  by  such  external  causes  as  en- 
croaching enlargements  of  the  liver  and  spleen,  left-sided  pleural  effu- 
sion, pneumothorax,  emphysema,  pericardial  effusion,  cardiac  hyper- 
trophy. 

Actual  diminution  in  the  size  of  the  stomach  is  indicated  if  the 
greater  curvature  is  observed  to  be  higher  than  a  level  of  1^  to  2  in. 
above  the  navel. 

AUSCULTATION 

Very  little  of  diagnostic  value  is  obtained  by  this  method  of  exam- 
ining the  stomach.  In  health,  a  sound  is  heard  at  the  cardiac  orifice 
of  the  stomach  while  liquid  is  passing  down  the  esophagus  through 
it,  and  there  is  normal  rhythmic  gushing  or  splashing  sounds,  which 
may  be  heard  over  the  stomach,  containing  air  and  water  only,  when 
the  body  is  shaken  sharply.  In  health,  also,  the  "  deglutition  mur- 
mur "  just  referred  to  is  often  followed  by  a  squirting  sound,  some 
three  to  seven  seconds  later,  as  the  liquid  passes  into  the  stomach  at 
the  cardiac  orifice ;  this  is  best  heard  while  listening  at  the  left  xipho- 
costal  angle.  A  cessation  or  marked  postponement  of  the  gurgle  or 
spurt  at  this  point  would  indicate  stenosis  of  the  cardiac  orifice, 
possibly  a  weakness  of  the  swallowing  muscles. 

Splashing  or  succussion  sounds,  which  may  be  elicited  by  a  bed- 
patient  simply  changing  position,  or  by  a  sudden,  lateral  movement 
of  the  body,  or  by  the  examiner  pressing  rapidly  with  the  fingers  of 
both  hands  alternately,  with  a  plunging  or  gently  poking  motion. 
This  is  done  between  the  level  of  the  navel  and  the  left  costal  border. 
If  this  splashing  can  be  detected  more  than  three  hours  after  a  meal 
of  light  character,  or  six  hours  after  a  heavy  meal,  persistently,  it  is 
evidence  of  atony  or  loss  of  motor  power  of  the  stomach,  or  of  dilation 
and  relaxation  of  the  stomach,  especially  if  the  sounds  are  audible 
below  the  transverse  umbilical  line.  Artificial  inflation  of  the  stom- 
ach will  enable  one  to  discover  this  phenomenon  still  more  readily. 

Bubbling,  gurgling,  and  clinking  sounds  may  be  heard,  often  in- 
fluenced by  the  respiratory  movements  while  auscultating  the  left  lung 
below  the  fourth  rib  or  interspace.  They  are  also  significant  of  gastric 
dilation,  with  gaseous  distention  and  some  liquid. 

Fizzing  sounds  indicate  active  fermentation  going  on,  or  the  anti- 
peristaltic  efforts  of  the  irritable  stomach  of  nervous  dyspepsia  to 
eruct  air  or  gas. 


388  PHYSICAL    DIAGNOSIS 

The  heart  sounds  may  assume  a  metallic,  resonant  quality  in  their 
transmission  through  a  dilated  stomach  over  which  one  is  listening. 


TOPOGRAPHIC    ANATOMY    OF   THE    INTESTINES 

The  topographic  anatomy  is  best  shown  in  Plate  IX.  It  is  to  be 
remembered  that  the  small  intestine  occupies  principally  the  middle 
portion  of  the  abdomen  below  the  waist  line. 

The  large  intestine  or  colon  takes  up  the  periphery  of  the  abdo- 
men, from  the  cecum  and  appendiceal  region  to  the  hepatic  flexure, 
near  the  right  costal  border,  thence  horizontally,  with  a  slight  curve 
downward  (transverse  colon)  to  the  splenic  flexure,  passing  thus  above 
the  umbilical  level,  to  end  in  the  sigmoid  flexure  lower  down,  near  the 
left  Poupart's  ligament.  The  cecum  is  more  superficially  seated  than 
the  upper  portion  of  the  ascending  colon. 

The  appendix  vermiformis  lies,  at  its  root,  at  the  middle  of  a  line 
drawn  from  the  anterior  superior  iliac  spine  to  the  navel,  near  the 
right  edge  of  the  rectus  muscle. 


PHYSICAL    EXAMINATION    OF   THE    INTESTINES 
INSPECTION 

Most  of  the  general  and  local  enlargements  of  the  bowels  have 
already  been  pointed  out  in  the  preceding  chapter.  Next  to  tympa- 
nites, the  increased  peristalsis  or  vermicular  movement  occurring 
above  an  intestinal  obstruction  is  most  important.  Obviously,  the 
less  the  area  of  distention  and  vermicular  movement  the  nearer  to  the 
duodenum  must  be  the  stenosis.  If  the  colon  alone  is  distended  with 
gas,  its  outline  may  be  determined  by  its  long,  sausagelike  swellings 
in  the  flanks. 

PALPATION 

Doughy  masses  of  fecal  accumulation  are  most  often  felt  in  con- 
stipated women  with  thin  abdominal  walls,  especially  over  the  cecum 
and  ascending  colon,  sometimes  over  the  sigmoid  flexure.  These  lumps 
are  also  to  be  differentiated  from  tumors  of  the  intestine  by  their 
disappearance  after  purgation  or  enemata.  Barely,  enteroliths  or 
bowel  calculi  may  be  felt. 

Gurgling  in  the  right  iliac  region  is  often  felt  in  typhoid  fever, 
but  may  be  detected  also  in  the  normal  individual  at  times,  when 


THE    STOMACH    AND    INTESTINES  389 

the  cecum  is  more  or  less  filled  with  gas,  and  irritability  of  the  intes- 
tinal motor  function  is  present. 

Peristaltic  motion  of  a  portion  of  intestine  is  palpable  above  a 
stenosis,  and  if  the  obstruction  be  chronic,  this  region  of  the  bowel 
is  moderately  hypertrophied  and  resistant  with  distention.  A  malig- 
nant thickening  and  stricture  of  the  colon  is  most  likely  to  be  found 
at  one  of  the  flexures  or  at  the  cecum. 

Appendiceal  thickening,  swelling,  and  abscess,  with  hardening  of 
the  overlying  and  reflexly  protecting  rectus  muscle,  are  characteristic- 
ally palpable  in  this  region. 

Tumors  of  the  colon  are  usually  cancerous,  and  may  be  felt  most 
frequently  either  in  the  cecum  or  at  the  sigmoid  flexure.  They  are 
hard,  often  nodular  and  irregular  in  outline,  with  oblong  masses  of 
impacted  feces  above  them.  Intestinal  neoplasms  are  rather  mobile 
within  the  hand  grasp,  but  fixed  as  to  location  relative  to  the  other 
parts. 

In  chronic  tuberculosis  of  the  bowel  one  feels  its  coils  as  firm, 
cordlike,  tangled  masses  through  the  thin  but  boardy  abdominal  walls. 

PERCUSSION 

Normally,  the  bowel  sound  is  tympanitic,  slightly  higher  pitched 
centrally  over  the  bunch  of  small  intestine  than  peripherally  over 
the  colon.  However,  as  the  conditions  of  volume  and  tension  and 
content  of  the  bowels  are  so  variable,  both  locally  and  generally,  abso- 
lute dependence  can  seldom  be  placed  upon  the  percutory  results. 
Light  percussion  strokes  are  best.  Auscultatory  percussion  is  more 
reliable  in  differentiating  large  from  small  intestine. 

Moderate  increase  in  gaseous  distention  of  the  bowel  produces 
louder  and  lower-pitched  tympany  than  normal,  and  over  a  greater 
extent  of  the  abdominal  surface,  encroaching  upon  the  hepatic  and 
splenic  dulness.  In  cases  of  extreme  distention,  as  in  severe  peri- 
tonitis, the  note  may  lose  its  distinctive  tympanitic  quality,  and  be- 
come more  like  the  harder,  "  band-box  "  sound  of  the  hyperresonance 
of  emphysema. 

To  outline  the  large  intestine  by  ordinary  percussion  the  colon  may 
be  filled  with  water  by  high,  postural  enemata,  and  the  dulness  thus 
noted.  On  the  other  hand,  by  auscultatory  percussion  the  colon  may 
be  differentiated  by  ballooning  it  with  air  pumped  into  it  through  a 
rectal  tube.  This  may  be  useful  where  congenital  or  acquired  pro- 
lapse and  flexure  are  suspected  from  obstructive  symptoms. 


390  PHYSICAL   DIAGNOSIS 

Areas  of  dulness  over  the  intestinal  region,  or  of  dull  or  muffled 
tympanitic  sound,  are  indicative  of  tumors  or  fecal  impactions  or 
accumulations,  the  latter  being  soon  inferable  if  they  are  movable 
under  catharsis  or  enteroclysis.  Cancer  or  malignant  stricture  of  the 
colon  is  more  apt  to  occur  at  the  anatomic  flexures,  and  the  small 
dull,  or  relatively  dull,  area  is  characteristically  separated  from  a  dis- 
tinct tympany  due  to  the  distention  above  and  adjoining  the  stricture. 
Stengel  claims  that  a  tumor  may  be  said  to  be  referable  to  the  wall 
of  the  previously  ascertained  colon  when,  by  auscultatory  percussion, 
the  stethoscope  being  placed  near  the  tumor  and  stroking  percussion 
being  made  over  and  toward  the  tumor  from  all  directions,  the  note 
over  the  tumor  resembles  that  over  the  adjacent  colon  more  nearly 
than  the  note  over  the  small  intestine  resembles  the  latter.  To  dis- 
cover the  dulness  over  an  intestinal  tumor  requires  deep  pressure 
with  the  pleximeter  finger. 

Chronic  thickening  of  the  cecum  and  appendix  from  recurrent 
attacks  of  appendicitis  may  be  indicated  by  the  persistence  of  moder- 
ate dulness  here  associated  with  increased  sense  of  resistance  (not 
due  to  muscular  rigidity).  A  chronic  appendiceal  abscess  may  also 
be  the  cause  of  circumscribed  dulness  in  this  region. 

AUSCULTATION 

Certain  rumbling,  fine  gurgling,  and  popping  sounds  occur 
rhythmically  over  the  intestines  in  health.  Intestinal  noises,  or 
borborygmi  (rumblings),  or  cooing,  or  splashing  sounds,  when  marked 
and  persistent,  are  all  suggestive  of  active  or  exaggerated  peristalsis, 
with  the  passage  of  gas  and  fluid  or  semifluid  matters  through  the 
loops  and  knuckles  of  gut.  Borborygmi  are  usually  associated  with 
flatulent  dyspeptic  conditions,  such  as  gastro-intestinal  catarrh,  espe- 
cially in  nervous  and  hysterical  women  and  those  who,  having  borne 
several  children,  have  lax  abdominal  walls. 

Loud  cooing  sounds,  if  associated  with  symptoms  of  intestinal 
obstruction,  may  have  diagnostic  value,  being  due  to  the  difficult 
passage  of  gas  and  liquid  through  the  narrowed  part  of  the  bowel; 
otherwise,  the  sounds  may  be  heard  occasionally  in  health.  Gurgling 
in  the  ileo-cecal  region  is  often  heard  in  typhoid  fever ;  it  is  developed 
or  increased  best  by  simultaneous  palpation.  Splashing,  audible  over 
the  cecum,  indicates  a  dilated  condition  of  this  portion  of  the  large 
intestine. 


CHAPTER    XVIII 
THE  LIVER,  SPLEEN,  AND  KIDNEYS 

TOPOGRAPHIC    ANATOMY    OF   THE    LIVER 

THE  liver  being  wedge-shaped,  so  that  about  three-fourths  of  it, 
or  the  thicker  portion,  lies  on  the  right  side  of  the  body,  thus  occupies 
topographically  the  right  upper  sextant,  or  the  right  hypochondriac 
region,  largely.  Its  thinner  portion  extends  into  the  epigastric  or 
upper  middle  sextant,  its  extreme  left  end  reaching  to  the  left  para- 
sternal  line.  The  upper  surface  of  the  liver  fits  snugly  into  the 
diaphragm,  its  dome  being  covered  by  the  concavity  of  the  right 
lung;  this  highest  point  of  the  right  lobe  reaches  the  level  of  the 
fourth  rib  (lower  border)  or  interspace;  at  its  left  end,  the  highest 
hepatic  point  is  at  the  fifth  interspace.  The  lower  surface  is  in  con- 
tact with  the  stomach,  transverse  colon,  duodenum,  and  right  kidney. 
The  anterior,  lateral,  and  posterior  surfaces  are  in  direct  relation, 
below  the  lung  limits,  with  the  right  lower  ribs  and  the  abdominal 
wall. 

The  sharp  antero-inferior  edge  passes  obliquely  upward  and  to  the 
left  from  the  lower  border  of  the  ribs,  with  which  it  practically  coin- 
cides, crossing  between  the  ninth  and  tenth  right  costal  cartilages; 
thence  across  the  epigastrium,  about  one-third  the  distance  between 
the  xiphoid  and  umbilicus;  thence  across  the  eighth  left  costal  car- 
tilage to  its  left  end  below  the  heart.  So  that  the  greatest  vertical 
extent  of  uncovered  or  parietal  liver  is  practically  in  the  right  mid- 
clavicular  line.  In  the  midaxillary  and  scapular  lines,  the  lower 
border  extends  along  the  eleventh  rib. 

The  vertical  extent  of  parietal  liver  thus  tapers  toward  the  spine, 
being  three  interspaces  wide  in  the  axillary  line  (eighth  to  tenth 
inclusive),  and  but  one  interspace  wide  in  the  scapular  line  (tenth 
to  eleventh),  as  well  as  to  the  left  across  the  epigastric  region.  The 
interlobar  notch  is  virtually  in  the  median  line. 

The  position  of  the  liver  is  affected  by  respiration;  deep  inspira- 
tion depresses  it  palpably.  Also,  when  the  patient  lies  upon  the  left 

391 


392 


PHYSICAL    DIAGNOSIS 


side,  the  left  lobe  of  the  liver  rises  higher  and  the  right  extends  lower, 
the  suspensory  ligament  serving  as  an  axis. 

Age  is  a  factor,  the  liver  being  proportionately  larger  in  children, 
so  that  its  lower  border  projects  about  an  inch  below  the  edge  of  the 
ribs  in  the  nipple  and  midaxillary  lines.  In  old  people,  on  the  con- 
trary, due  to  contraction  and  atrophy  of  the  parenchyma,  the  liver  has 
diminished  in  size  so  that  its  lower  border  lies  about  one  inch  above  the 
rib  edge. 


Lower  border  J9 
of  Inner  _3 


Lower  border 
of  liver 

Gall-bladder 


FIG.  82.— SHOWING  THE  POINTS  WHICH  DETERMINE  THE  SIZE  AND  POSITION  OP  THE 
NORMAL  LIVER.  Horizontal  shading  =  portion  of  liver  overlapped  by  lung;  ver- 
tical shading  =  portion  of  liver  overlapped  by  heart.  (Butler.) 

The  gall-bladder  projects  from  the  under  surface  of  the  liver 
opposite  the  ninth  right  costal  cartilage,  close  to  where  the  inferior 
edge  of  the  liver  passes  under  the  right  border  of  the  ribs,  and  there- 
fore just  within  the  right  nipple-line. 

EXAMINATION    OF    THE    LIVER 

INSPECTION 

The  body  should  be  in  the  dorsal  position,  with  the  shoulders 
moderately  elevated,  and  should  face  a  good  light.  No  evidences  of 
the  liver  can  be  seen  in  the  healthy  adult. 


PLATE    X 


«$f 


SURFACE  RELATIONS  OF  THE  LIVER. 


THE    LIVE!?,    SPLEEN,    AND    KIDNEYS  393 

Bulging  or  fulness  of  the  right  hypochondrium,  or  also  of  the 
region  below  the  border  of  the  ribs  and  of  the  epigastrium,  indicates 
enlargement  of  the  liver.  In  very  young  persons,  owing  to  the  flexi- 
bility of  the  lower  ribs,  moderate  hepatic  enlargements  are  more 
noticeable,  while  in  old  persons  only  the  most  marked  enlargements 
cause  visible  projection  of  the  stiffer  ribs.  A  more  or  less  thin 
abdominal  wall,  moderately  full  in  contour,  also  contributes  to  a 
plainer  visibility  of  enlarged  liver.  The  downward  movement  of  the 
latter  during  inspiration  is  characteristic.  In  some  instances  the  fact 
that  the  enlargement  of  the  liver  is  uniform  may  be  detected  by  the 
even  surface  of  the  swelling,  as  from  amyloid  or  fatty  degeneration, 
leukcmic  or  malarial  hyperplasia;  or  that  it  is  irregular,  lump,  or 
nodular,  may  be  significant  of  cancer,  abscess,  hydatids,  or  syphilitic 
disease. 

If  the  bulging  is  especially  marked  below  the  margin  of  the  ribs, 
without  projection  of  the  latter,  downward  displacement  of  the  liver 
is  indicated.  This  may  be  caused  by  and  associated  with  marked 
emphysema  of  the  right  lung,  with  pleural  effusion,  empyema,  or 
pneumothorax  of  the  right  side,  subdiaphragmatic  abscess,  or  even 
with  a  concomitant  heavy  enlargement  of  the  organ. 

The  lower  edge  of  the  liver  may  sometimes  be  seen  as  a  linear 
shadow  or  sharp  projection,  movable  with  respiration,  in  cases  of 
enlargement  or  displacement,  as  from  "wandering  liver,"  which 
occurs  in  certain  women  with  general  ptosis  of  the  abdominal  organs 
and  soft,  flabby  relaxation  of  the  belly  walls. 

A  hepatic  venous  pulsation  may  be  visible,  accompanying  the 
enlargement  of  passive  congestion  due  to  valvular  incompetency,  as 
tricuspid  regurgitation. 

PALPATION 

By  touch,  the  edge  of  the  liver  can  hardly  be  felt  in  the  normal 
individual  of  moderate  abdominal  wall  thickness,  either  at  the  lower 
border  of  the  ribs  or  where  it  crosses  the  epigastrium  (dense  fibro- 
muscular  resistance).  In  women  having  thin,  lax  abdominal  walls, 
however,  the  lower  border  of  the  liver  may  be  felt  satisfactorily, 
especially  during  the  downward  inspiratory  movement.  In  children, 
it  may  be  felt  with  comparative  ease. 

The  usefulness  of  palpation  of  the  liver,  over  against  the  other 
methods,  makes  it  important  to  practise  its  technic  with  extreme 
care,  frequency,  and  patience.  The  patient  must  be  in  a  relaxed 
dorsal  position.  The  examiner's  hands,  indubitably  warm,  may  first 


394  PHYSICAL    DIAGNOSIS 

grasp  the  abdominal  wall  gently  so  as  to  estimate  its  thickness  and 
resistance  for  a  proper  allowance.  The  finger-tips  are  applied  flatly 
to  the  abdominal  wall  below  the  ribs,  approaching  upward,  while 
sitting  at  the  patient's  right  side.  A  fold  of  skin  may  now  be  pushed 
up,  and  then  immediately  the  fingers  are  depressed  sufficiently  to  feel 
the  lower  edge  of  the  liver,  especially  just  after  it  descends  with  in- 
spiration. Abrupt,  poking  efforts  must  be  avoided  so  as  to  eliminate 
the  interference  of  hardening  of  a  contracted  rectus  muscle.  Another 
way  is  to  stand  facing  the  feet  of  the  patient,  and  hook  the  fingers 
around  the  rib  borders,  and  thus  feel  the  hepatic  margin  pushing 
under  their  tips  with  inspiration. 

Palpation  of  the  liver  enables  one  to  judge  of  its  size  and  form, 
its  surface  and  its  consistency. 

(1)  Size  and  Form. — These  are  determined  mainly  by  studying 
the  lower  edge  of  the  organ.  When  the  long,  distinct  edge  of  the 
liver  is  felt  below  the  border  of  the  ribs,  it  may  mean  either  enlarge- 
ment or  displacement,  or  both,  depending  upon  the  associated  condi- 
tions which  might  cause  one  or  the  other,  or  both.  If,  at  the  same 
time  that  the  lower  border  of  the  liver  is  found  to  be  depressed,  per- 
cussion discovers  that  the  upper  border  is  not  depressed,  then  of 
course  the  organ  is  enlarged.  If,  on  the  other  hand,  it  can  be  demon- 
strated that  there  is  a  right-sided  pleural  effusion,  pneumothorax, 
subdiaphragmatic  abscess,  or  even  marked  emphysema,  it  is  then 
probable  that  the  inferior  border  is  depressed  because  of  displace- 
ment of  the  liver,  although  in  the  last-named  disease  there  is  usually 
a  simultaneous  enlargement  from  passive  congestion  of  the  liver.  As 
pointed  out  by  Vierordt,  however,  "when  a  liver  is  markedly  dis- 
placed downward,  the  impression  is  easily  made  that  it  is  also  en- 
larged, because  by  traction  about  its  transverse  axis  it  becomes  pari- 
etal to  a  larger  extent."  Downward  displacement  of  the  lower  border 
of  the  liver  may  also  be  found  as  the  result  of  tight  lacing  ("  corset 
liver  "),  and  of  a  general  laxness  of  the  abdominal  viscera  ("  wander- 
ing liver  ").  In  the  latter  case  the  liver  may  be  pushed  upward  with 
the  finger. 

An  approximate  idea  of  the  form  of  the  liver  may  be  obtained 
by  noting  the  character  of  its  edge,  and  the  trend  the  latter  takes. 
Much  of  this  recognition  depends  upon  the  extent  to  which  the  liver 
is  closely  apposed  to  the  abdominal  wall.  The  uniform  and  irregu- 
lar enlargements  have  already  been  mentioned.  A  seriatim  indi- 
cation of  the  principal  conditions  affecting  the  liver  edge  is  here 
given : 


THE    LIVER,    SPLEEX,    AXD    KIDNEYS  395 

(a)  PASSIVE  ENGORGEMENT  (later  stages  of  uncompensated  heart 
disease,  and  in  advanced  emphysema). — The  liver  edge  protrudes 
slightly,  is  smooth  and  well  defined,  and  takes  the  direction  of  the 
normal  virtually. 

(&)  FATTY  LIVER. — The  organ  is  uniformly  enlarged  and  normal 
in  shape.  The  inferior  border  is  smooth  and  slightly  rounded,  and  is 
felt  lower  down  than  the  congested  liver. 

(c)  HYPERTROPHIC  (BILIARY)  CIRRHOSIS. — Considerable  enlarge- 
ment may  be  noted  here,  the  lower  hepatic  border  being  often  felt 
as   low  as   the  umbilical  level,   and  having  a  smooth,  well-defined, 
thickened  outline. 

(d)  AMYLOID  LIVER. — This  is  also  a  large  liver  having  a  smooth, 
often  sharp  lower  border,  or  perhaps  slightly  rounded.     The  same 
features  are  usually  present  in 

(e)  DIFFUSE  SYPHILITIC  HEPATITIS,  and  in 
(/)  LEUKEMIC  LIVER. 

(g)  CANCEROUS  LIVER. — Marked  enlargement  is  present,  and  the 
lower  border  is  thickened,  irregular  in  outline  and  direction,  nodular 
and  notched. 

(h)  SYPHILIS  OF  THE  LIVER. — This  may  have  some  of  the  char- 
acteristics of  the  preceding  condition,  with  perhaps  less  massiveness 
of  outline,  and  more  irregularity,  especially  in  deep  fissuring  of  the 
edge. 

(t)  ABSCESS  MAY  BE  SINGLE  OR  MULTIPLE. — In  cases  of  the 
latter  the  liver  may  exhibit  uniform  enlargement.  In  some  instances 
the  abscesses  may  be  palpable  as  distinct  prominences  from  the  under 
surface  of  the  liver,  especially  the  right  lobe. 

(_/')  HYDATIDS. — The  edge  of  the  liver  affords  their  discovery  when 
sufficiently  large,  parietal,  globular,  and  subject  to  signs  of  fluctuation. 

(2)  Surface. — The  liver  surface  can  be  perceived  in  cases  of  suffi- 
cient enlargement,  with  thinness  and  looseness  of  the  belly  wall. 
When  smooth  and  even,  the  liver  may  be  engorged,  fatty,  leukemic, 
amyloid,  or  malarial.  A  granular  surface  indicates  cirrhosis,  best 
felt,  of  course,  in  the  contracting  stage  of  a  hypertrophic  liver  before 
sufficient  atrophy  has  taken  place  to  draw  it  beneath  the  ribs.  The 
common  association  of  ascites  with  the  atrophic  cirrhosis  makes  it 
necessary,  in  order  to  palpate  the  under  surface  of  the  liver  at  the 
rib  border,  to  displace  the  liquid  by  a  brusk  poking  movement  with 
the  tips  of  the  fingers. 

Irregular,  nodelike  elevations  in  a  thin,  emaciated  consumptive 
would  hint  toward  tuberculous  peritonitis. 


396  PHYSICAL    DIAGNOSIS 

A  largely  nodular  or  losselated  surface  betokens  secondary  cancer 
of  the  liver.  The  tumors  vary  in  size  from  a  cherry  to  a  walnut,  or 
even  a  small  apple;  they  are  rough,  and  not  infrequently  manifest 
to  the  touch  small  depressions  on  their  summits  (cancer  navel). 
When  a  distinctly  lobulated  liver  is  felt,  with  flat  elevations,  a  syphi- 
litic gummatous  organ  is  probable.  Superficial  abscesses  and  echino- 
coccus  cysts  may  be  inferred  with  round,  smooth,  more  or  less  fluctu- 
ating eminences. 

(3)  Consistency. — This  is  uniformly  and  moderately  increased  in 
chronic  engorgement,  leukemia,  and  hypertrophic  cirrhosis ;  uniformly 
and  markedly  increased  in  amyloid  liver ;  uniformly  non-resistant  and 
somewhat  elastic  in  fatty  liver;  irregularly  increased  in  firmness  in 
cancer  and  syphilis,  according  to  the  amount  of  scirrhous  and  con- 
nective tissue  in  these  respective  conditions.  Abscess  and  hydatid 
cysts  give  rise  to  more  or  less  doughy  sense  of  fluctuation,  and  the 
so-called  hydatid  thrill  may  sometimes  be  detected  over  large  super- 
ficial cysts — a  peculiar  whizzing  sensation  elicited  by  giving  staccato 
or  short,  quick  strokes  with  the  fingers. 

The  gall-bladder  cannot  be  palpated  normally.  When  distended 
moderately,  it  may  be  felt  as  a  small,  soft,  ill-defined,  rounded  mass 
at  the  edge  of  the  ninth  right  costal  cartilage.  A  distinctly  palpable, 
enlarged  gall-bladder  occurs  as  a  pear-sized  and  -shaped,  smooth, 
often  soft,  tumor.  The  narrow  or  fixed  portion  of  the  tumor  corre- 
sponds to  the  costal  intersection  of  a  line  drawn  from  the  right 
acromion  process  to  the  navel,  just  outside  the  right  edge  of  the  right 
rectus  muscle.  The  large  or  dependent  end  is  movable  in  the  arc 
of  a  circle;  it  may  be  moved  almost  or  quite  to  the  median  line,  and 
up  and  to  the  right  under  the  liver,  but  not  downward.  It  is,  how- 
ever, movable  downward  with  deep  inspiration  along  with  the  liver, 
which  is  characteristic. 

The  principal  causes  of  enlarged  gall-bladder  may  be  enumerated 
as  follows:  (a)  Distention  by  fluid  from  some  obstructive  disease  or 
stenosis  affecting  the  common  or  cystic  ducts,  or  from  inflammation, 
causing  biliary  engorgement,  retention  of  mucus  (hydrops),  or  pus; 
(&)  distention  by  gall-stones;  (c)  malignant  or  benign  growths. 

Distention  of  the  gall-bladder  by  fluid  accumulation  feels  soft  and 
elastic,  and  the  tumor  may  sometimes  be  diminished  by  slowly  ex- 
pressing part  of  its  contents  into  the  duodenum.  Moderate  enlarge- 
ment with  density  of  feel  may  indicate  inflammatory  thickening. 
The  presence  of  gall-stones  gives  rise  to  a  sensation  of  movable  nodules 
("bag  of  nuts")  if  the  abdominal  wall  is  thin  and  lax  enough;  a 


28 


TABLE   FOR  THE   DIAGNOSIS  OF 


SlZB  OF  THE 

LIVER. 

CONSISTENCY  OF  THE 
LIVER. 

BORDER  OF  THE  LIVER. 

SURFACE  OF  THE 
LIVER. 

Coarse, 

Dimi- 
nution. 

Enlarge- 
ment. 

Soft  to 
fluctu- 
ating. 

a  little 
harder 
than 

Hard. 

Smooth 
to 
sharp. 

Thick, 
rounded. 

Uneven 
lobular. 

Smooth. 

Un- 
even. 

normal. 

Simple 

Abscess 

Fatty 

Simple 

Cir- 

Fatty 

Fatty 

Cir- 

Hyper- 

Cir- 

atrophy. 

of  the 

liver. 

atrophy. 

rhosis. 

liver. 

liver. 

rhosis 

emia. 

rhosis. 

Atrophic 

liver. 

Abscess 

Icterus 

Syphilis 

Icterus. 

Hyper- 

(only  in 
rare 

Fatty 

Ab- 

nutmeg 
liver. 

Cir- 
rhosis. 

Dia- 
betic 
liver. 

Icterus 

of  the 
liver. 

Echino- 
coccus 

liver. 

Hyper- 
emia. 

of  the 
liver. 

Con- 
nective 

Hyper- 

plasia 
(some- 
times 

emia. 

Amy- 
loid. 

cases 
at  all 
palpa- 
ble). 

liver. 

Icterus 
liver. 

scess. 

Syph- 

ilis 
of  the 

Syphilis 
of  the 
liver 

liver. 

Weil's 
disease. 

unilocu- 
laris. 

tissue 
hyper- 
plasia. 

slightly 
rounded). 

Echino- 

Ab- 
scess. 

Carci- 

Ele- 
phan- 
tiasis. 

liver. 

Car- 
cinoma. 

(atrophie 
form 

Fatty 

Echino- 
coccus 

coccus. 

noma. 

Amv- 
loid 

Echino- 

rather 
rare). 

Acute 

liver. 

Passive 
hyper- 

multiloc- 
ularis 
(becom- 
ing 

Simple 
atrophy. 

Syphilis 
of  the 
liver. 

liver. 

Leuke- 
mia. 

coccus. 

yellow 
atrophy 
of  the 

liver. 

emia. 
Syph- 

ills 

soft). 

Amy- 
loid 

Dia- 
betic 
liver. 

of  the 

liver. 

liver. 

Acute 

P 

yellow 

Leuke- 
mia. 

noma. 

atrophy 
of  the 

liver. 

Connect- 

ive 

tissue 

hyper- 

plasia 

of  the 

liver. 

Amyloid 

liver. 

Carci- 

noma 

of  the 

liver. 

Echino- 

coccus 

of  the 

liver. 

NOTE. — The  order  of  the  diseases  in  these  columns  is  generally  so  arranged  that  the 

the  farther  down  in  the 


DISEASES   OF  THE   LIVER   (AFTER   LEUBE) 


JAUNDICE. 

ASCITES. 

PAIN. 

ENLARGEMENT  OP  THE 
SPLEEN. 

Absent. 

Rare. 

Frequent. 

Absent. 

Present. 

Present. 

Absent. 

Present. 

Amyloid. 

(Onlv 
if  bile 

Abscess. 

Fatty 
liver. 

Carci- 
noma. 

Echino- 
coccus 

Carci- 
noma. 

Echino- 
coccus 

Adhesive    ducts  are 

Hyper- 

multilocu- 

unilocu- 

pyle- 
phlebitis. 

Fatty 
liver. 

directly 
affected 
by  the 
path- 
ologic 
process 
in:) 

em  i  a. 
Cirrhosis. 

Carci- 
noma. 

Echino- 

Elephan- 
tiasis 
hep. 

Icterus 
liver. 

Echino- 

Syphilis 
with 
cicatrices. 

Echino- 
coccus 
multilocu- 
laris. 

laris. 

Acute 
yellow 
atrophy 
of  the 
liver. 

Fatty 
liver. 

laris 
(rarely 
by  stasis 
in  the 
portal 
vein 
system). 

Echino- 
coccus 
unilocu- 
laris. 

Syphilis 
of  the 
liver. 

coccus 
multilocu- 
laris. 

Elephan- 
tiasis 
hep. 

Icterus 

coccus 
unilocu- 
laris. 

Abscess. 

Cirrhosis. 

Pyle- 
phleb. 
spec, 
adhesiva. 

Amyloid 

Carci- 
noma. 

Syphilis 
of  the 
liver. 

Abscess. 

Hyper- 
emia  of 
the  liver. 

Syphilis 
of  the 
liver. 

Cirrhosis. 

liver. 

(through 
the 

Echino- 

original 
process). 

coccus 
multilocu- 
laris. 

Hyper- 

Hyper- 

em  ia 
(in  later 

stages 

trophic 
cirrhosis. 

constant). 

Amyloid 

liver. 

Further- 

more, 

through 

general 

infection 

caused  by 

acute 

yellow 

atrophy  of 

the  liver. 

Abscess 

of  the 

liver. 

Weil's 

disease. 

respective  symptom  is  the  more  characteristic  of  the  special  affection  of  the  liver, 
column  it  is  quoted. 


THE    LIVER,    SPLEEX,    AXD    KIDNEYS  397 

distinct  friction  or  grating  sensation  may  be  palpable.  A  firm,  irregu- 
lar mass  signifies  carcinomatous  thickening  or  growth. 

The  fluid  distention  of  the  gall-bladder  with  bile  may  be  the 
result  of  gall-stones  in  the  common  duct,  or  of  an  obstructive  duo- 
denal catarrh,  or  of  a  roundworm  (ascaris  lumbricoides) ,  or  of  some 
growth  adjacent  compressing  the  duct,  as  cancer  of  the  head  of  the 
pancreas. 

Differential  Diagnosis. — While  tumors  of  the  gall-bladder  may  be 
simulated  by  hydatid  cysts,  and  by  abnormal  prolongations  of  the 
lower  border  of  the  liver,  these  conditions  occur  so  rarely  as  to  need 
no  more  than  the  mentioning  here. 

Movable  or  floating  kidney,  which  is  more  often  found  on  the  right 
side,  has  frequent  and  important  differential  bearing.  Both  it  and 
the  distended  gall-bladder  are  smooth  and  rounded,  but  the  former 
is  characteristically  bean-shaped,  the  latter  pear-  or  gourd-shaped. 
The  kidney  has  also  the  notch  of  the  hilum,  and  if  much  displaced, 
in  some  instances  the  pulsations  of  the  renal  artery  may  be  felt.  The 
kidney  has  a  uniformly  fleshy  feel,  whereas  the  gall-bladder  may  be 
soft  with  liquid,  rough  with  calculi,  or  hard  and  nodular  with  cancer. 
Again,  the  pear-shaped  gall-bladder  is  usually  so  superficial  that  it 
may  be  felt  by  direct  palpation  in  front,  while  the  displaced  kidney 
is  more  deeply  palpable,  and  usually  requires  counter  pressure  through 
the  soft  lumbar  tissues  from  behind.  Also,  the  kidney  has  a  wider 
range  of  mobility,  particularly  in  a  vertical  direction,  whereas  the 
enlarged  gall-bladder  swings  in  a  short,  circumscribed  arc,  with  its 
long  axis  as  the  radius;  it  is  frequently  possible  to  slip  the  kidney 
under  the  fingers  in  various  directions.  Respiratory  mobility  affects 
the  distended  gall-bladder  more  than  it  does  the  kidney  unless,  of 
course,  the  latter  be  floating  far  below  the  liver.  Finally,  gaseous 
distention  of  the  colon  makes  the  gall-bladder  prominent,  the  kidney 
less  so,  or  completely  prevents  it  being  felt. 

PERCUSSION 

There  are  two  so-called  areas  of  liver  dulness,  one,  the  area  of 
absolute  dulness,  representing  that  portion  of  the  organ  which  is 
parietal — that  is,  in  apposition  with  the  lower  ribs  without  the  inter- 
vention of  lung  tissue;  the  other,  the  area  of  relative  dulness.,  repre- 
senting the  narrow  zone  above  and  adjoining  the  absolute  area,  where 
the  liver  is  covered  by  a  thin  layer  of  lung.  The  vertical  extent  of 
absolute  liver  dulness  is  widest  in  the  nipple-line,  beyond  which  it 


398  PHYSICAL   DIAGNOSIS 

tapers  gradually  around  the  chest  to  an  interspace  in  width  in 
the  right  scapular  line,  and  more  sharply  to  the  left  in  front, 
until  it  passes  into  the  cardiac  dulness,  from  which  it  cannot  he 
definitely  delimited,  at  about  the  sixth  rib  within  the  left  para- 
sternal  line. 

The  lower  border  of  normal  liver  dulness  corresponds  closely  with 
its  anatomic  limits;  that  is,  from  the  right  midclavicular  line  back- 
ward it  begins  at  the  borders  of  the  ribs  (tenth  rib  in  the  axillary 
line,  eleventh  rib  in  the  scapular  line).  Here,  anteriorly,  it  is  neces- 
sary to  percuss  gently  from  below,  so  as  to  avoid  eclipsing  the  first 
signs  of  dulness  of  the  thin  edge  of  the  liver  by  the  adjacent  colonic 
tympany. 

The  upper  border  of  absolute  liver  dulness — that  is,  the  lung-liver 
boundary — naturally  begins  where  lung  resonance  absolutely  ceases: 
at  the  base  of  the  ensiform  cartilage  in  the  middle  line,  at  the  sixth 
rib  in  the  nipple-line,  the  eighth  rib  in  the  midaxillary  line,  the  tenth 
rib  in  the  scapular  angle  line.  This  is  at  the  same  time  the  lower 
border  of  relative  dulness. 

The  upper  border  of  relative  dulness  is  about  one  rib  higher  all 
around ;  and  above  the  fifth,  seventh,  and  ninth  ribs,  in  the  respective 
lines  just  mentioned,  passes  at  once  into  clear  pulmonary  resonance. 

Posteriorly,  near  the  spine,  the  lower  border  of  liver  dulness  can- 
not be  separated  from  the  kidney  dulness.  In  the  epigastric  region 
it  is  often  difficult  to  ascertain  the  lower  border  of  liver  dulm-ss 
because  of  confusing  gastric  and  intestinal  tympany,  on  the  one  hand, 
and  because  of  dulness  of  firm,  thick  bellies  of  the  rectus  muscle. 
on  the  other. 

We  percuss  downward  from  the  lung  to  determine  the  upper  bor- 
der of  hepatic  dulness,  and  upward  from  the  abdomen  to  determine 
the  lower  border.  The  normal  boundaries  vary  somewhat  in  different 
individuals,  according  to  the  size  and  shape  of  the  liver,  and  the 
condition  of  the  lungs  and  adjacent  organs,  as  well  as  the  formation 
of  the  bony  chest  case.  Besides,  the  upper  border  of  dulness  is 
displaced  by  deep  breathing  (active  mobility). 

The  total  width  of  liver  dulness  (absolute  and  relative  combined) 
is  about  four  inches  in  the  left  midclavicular  line,  six  inches  in  the 
midaxillary  line,  and  three  inches  in  the  scapular  line.  In  children, 
the  lower  border  of  dulness  is  normally  lower  than  in  adults,  and  the 
upper  border  higher,  because  of  the  relatively  greater  size  of  the  organ. 
Per  contra,  the  lower  limit  of  hepatic  dulness  is  a  little  higher  in 
the  aged,  because  of  senile  shrinkage. 


THE    LIVER,    SPLEEX,    AM)    KIDNEYS  399 

Auscultatory  percussion  may  be  applied  with  precise  results  in 
outlining  the  liver  borders,  and  in  determining  whether  an  adjacent 
tumor  is  an  outgrowth  of  the  liver  itself,  or  whether  it  is  conjoined 
to  a  neighboring  viscus. 

Pathologic  Relations  of  Changes  of  the  Area  of  Liver  Dulness. — 
(1)  The  UPPER  BOUNDARY  may  be  found  to  be  higher  than  normal. 
In  the  first  place,  this  may  be  due  to  some  thoracic  condition,  and 
thus  becomes  an  apparent  instead  of  an  actual  increase  of  liver  dul- 
iirss  upward.  The  causes  may  be  lobar  pneumonia,  pleural  effusion, 
tumors  of  the  lung  and  pleura,  marked  thickening  of  the  pleura, 
subphrenic  abscess,  and  retraction  of  the  lung,  causing  more  of  the 
liver  to  become  parietal.  In  cases  of  large  pleural  effusion,  the  liver 
is  displaced  downward,  with  consequent  lowered  inferior  boundary 
of  dulness,  and  extensive  total  dulness  from  the  top  of  the  effusion 
to  the  lowest  point  of  liver  dulness.  With  small,  beginning  pleural 
effusions  it  may  be  difficult  to  eliminate  liver  dulness  extended  up- 
ward unless  the  history  and  other  evidences  point  to  thoracic  disease. 

Real  displacement  upward  of  the  upper  boundary  of  liver  dulness 
may  occur  from  marked  enlargement  of  the  organ,  tumor  of  its  con- 
vexity, or  upward  displacement.  In  the  former  state  the  lower  bound- 
ary is  simultaneously  deeper  than  normal.  A  tumor  is  indicated  if 
the  raised  upper  boundary  of  dulness  is  irregular  in  outline,  or  a 
large  abscess  or  hydatid  cyst  may  be  present.  The  lower  border  of 
liver  dulness  may  also  be  depressed  moderately.  Displacement  of  the 
liver  upward,  as  from  ascites  or  intense  tympanites,  is  accompanied 
with  upward  displacement  of  the  lower  border  of  liver  dulness,  and 
less  area  of  dulness  generally,  because  of  the  diminished  extent  of  the 
organ,  which  is  parietal. 

(2)  UPPER  BOUNDARY  of  liver  dulness  is  lower  than  normal.  This 
results  from  any  condition  in  which  there  is  encroachment  downward 
of  the  extent  of  clear  sound  over  the  right  thorax.  If  at  the  same 
time  the  lower  boundary  of  liver  dulness  is  displaced  downward,  the 
cause  is  either  marked  emphysema  or  pneumothorax.  In  the  former 
condition  the  simultaneous  low  position  of  both  boundaries  may  be 
accompanied  with  decided  low  position  of  the  lower  border  also,  be- 
cause of  the  enlargement  of  the  liver  due  to  the  engorgement  which 
usually  goes  with  advanced  emphysema. 

A  low  position  of  the  upper  boundary  of  liver  dulness  without 
simultaneous  lowered  inferior  border  may  be  found  temporarily  as  an 
accompaniment  of  compensatory  emphysema,  where  the  lung  fills  the 
complementary  pleural  sinus  above  the  diaphragm. 


400  PHYSICAL    DIAGNOSIS 

(3)  The  LOWER  BOUNDARY  of  liver  dulness  is  higher  in  upward 
displacement  of  the  organ,  as   from   ascites,  tympanites,  and  enor- 
mous abdominal  tumors  pressing  upward;  also,  in  atrophy  (cirrhotic) 
of  the  liver. 

(4)  The  LOWER  BOUNDARY  of  liver  dulness  is  depressed  in  en- 
largement and  downward  dislocation,  as  has  already  been  pointed  out 
in  connection  with  associated  displacement  of  the  upper  boundary. 
The  lower  line  of  dulness  is  more  vertical  or  horizontal  according 
to.  the  cause,  degree,  and  side  affected  in  depressing  the  organ.     A 
large  pleural   effusion  on  the  right  side  will  produce  the  greatest 
tilting  downward  of  the  right  lobe  of  the  liver,  and  consequently  a 
sharp  slope  upward  toward  the  left  of  the  lower  border  of  dulness. 
On  the  other  hand,  a  heavy  and  abundant  pericardia!  effusion  will 
cause  the  lower  border  of  liver  dulness  to  take  a  more  horizontal 
trend  because  of  the  pressure  upon  the  left  lobe. 

DIMINISHED  TOTAL  AREA  OF  LIVER  DULNESS  is  most  commonly 
caused  by  atrophic  cirrhosis  of  the  organ;  rarely  by  acute  yellow 
atrophy.  An  apparent  decrease  in  the  area  of  hepatic  flatness  may 
be  due  to  encroachment  by  distended  (emphysematous)  lung  above, 
or  by  distended  stomach  or  colon,  or  pneumoperitoneum  (from  ulcer- 
ous or  traumatic  perforation  of  the  gut)  from  below. 

Absence  of  liver  dulness  indicates  a  complete  dislocation  of  the 
liver,  either  as  wandering  liver  or  as  a  part  of  inversion  of  the  viscera. 

Apparent  enlargement  of  the  liver  downward  may  be  misjudged 
because  of  contiguous  dull  areas,  such  as  arise  from  fecal  accumula- 
tions in  the  transverse  colon,  tumors  of  the  colon  or  stomach,  renal 
and  large  ovarian  tumors,  pancreatic  cyst,  tumors  of  the  omentum 
(sarcomatous  or  tuberculous),  and  ascites.  It  may  also  be  mistakenly 
inferred  on  account  of  a  moderately  prolapsed  position  of  the  organ. 

Two  alterations  of  the  relative  liver  dulness,  of  minor  diagnostic 
value,  may  be  noted :  it  is  high  in  association  with  great  enlargement 
upward  of  the  liver,  and  consequent  high  vertical  position  of  the 
anterior  wall  of  the  diaphragm;  it  is  low  from  pneumothorax  and 
severe  emphysema,  where  the  diaphragm  is  thus  flattened  down  so 
that  its  anterior  portion  leaves  the  thoracic  wall  somewhat  perpen- 
dicularly (Vierordt). 

AUSCULTATION 

By  this  method  one  may  discover  a  perihepatitis  by  recognizing 
fine  crepitations,  even  rubbing  or  crumpling  sounds  in  the  lower 
interspaces,  between  the  right  parasternal  and  axillary  lines. 


THE    LIVEK,    SPLEEN,    AND    KIDNEYS  401 

A  continuous,  soft  blowing  murmur  may  be  heard  over  the  liver 
in  some  instances  of  tricuspid  regurgitation. 

A  gall-stone  crepitus  or  grating  sound  may  be  audible  over  the 
gall-bladder  in  certain  cases  during  deep  breathing,  palpation,  or 
movable  pressure  with  the  stethoscope. 


TOPOGRAPHIC   ANATOMY   OF   THE   SPLEEN 

The  spleen  has  an  oval  shape,  its  long  axis  being  parallel  with 
the  ribs  under  which  it  lies  in  the  left  infra-axillary  region,  these 
ribs  being  the  ninth,  tenth,  and  eleventh.  Posteriorly,  it  reaches 


FIG.  83. — SHOWING  THE  SURFACE  TOPOGRAPHY  OF  THE  SPLEEN.  Shaded  area  =  por- 
tion overlapped  by  lung.  Numbered  arrows  show  the  lines  along  which  percus- 
sion should  be  conducted.  (Butler.) 

nearly  to  the  spine,  about  one  inch  from  the  tenth  dorsal  vertebra. 
Laterally,  it  approaches  closely  to  the  midaxillary  line,  so  that  its 
length  averages  about  four  and  one-half  inches,  with  its  corresponding 
axis  running  a  course  downward  and  forward.  The  spleen's  breadth 


402  PHYSICAL    1)1  A(i.\OSIS 

is  about  three  inches.     The  notch  on  its  anterior  border  is  palpable 
only  when  the  organ  is  enlarged. 

Its  relations  to  other  structures  should  be  recalled.  It  lies  in 
close  contact  with  the  under  surface  of  the  diaphragm  as  it  arches 
upward.  Postero-inferiorly,  the  spleen  overlaps  a  small  portion  of 
the  left  kidney,  and  anteriorly,  it  lies  in  contact  with  the  outer  portion 
of  the  greater  curvature  of  the  stomach  and  the  splenic  flexure  of 
the  colon.  Topographically,  the  spleen  is  in  contact  with  the  lower 
portion  of  the  thorax  only  with  its  lower  two-thirds,  the  upper  third 
being  separated  from  the  ribs  by  the  diaphragm  and  lower  border 
of  the  left  lung.  This  parietal  portion  is  somewhat  variable  on  ac- 
count of  the  mobility  of  the  lung  as  affected  by  the  depth  of  the 
respirations  and  the  posture  of  the  body.  The  upper  and  anterior!) 

I  border  of  the  spleen  forms  the  spleen-lung  angle  at  about  the  ninth  | 
rib  in  the  posterior  axillary  line,  when  the  body  is  in  the  dorsal' 
position,  or  it  may  be  at  the  anterior  axillary  line  when  in  the  right- 
sided  position.     The  lower  splenic  border  runs  backward  along  the 
eleventh  rib. 


EXAMINATION    OF   THE   SPLEEN 

INSPECTION 

From  its  position  beneath  the  ribs,  it  is  obvious  that  the  normal 
spleen  can  neither  be  inspected  nor  palpated.  Only  when  greatly 
enlarged  can  the  spleen  be  inspected,  because  of  the  bulging  down- 
ward and  forward  from  under  the  left  hypochondrium,  often  distend- 
ing the  greater  portion  of  the  abdomen.  The  antero-inferior  edge 
of  such  a  greatly  enlarged  spleen  may  exhibit  a  sharply  'outlined, 
oval-shaped  border  of  slight  elevation  of  the  overlying  skin.  This 
edge  and  the  whole  tumor  move  with  respiration.  I  have  noticed 
even  a  slight  depression,  corresponding  to  the  splenic  notch,  in  two 
cases  of  enormous  splenic  enlargement  where  the  belly  was  tensely 
filled. 

PALPATION 

The  ease  and  accuracy  with  which  the  pathologic  spleen  may  be 
palpated  depends  upon  the  degree  of  its  enlargement,  the  technical 
skill  of  the  examiner,  and  the  resistance  of  the  abdominal  wall.  Slight 
and  moderate  splenic  enlargements  call  for  a  practised  and  patient 
technic  for  their  detection.  Under  these  circumstances  the  antero- 
inferior  edge  may  be  felt  to  project  just  beyond  the  free  border  of 


THE    LIVER,    SPLEEN,    AND    KIDNEYS 


403 


the  ribs,  especially  during  a  deep  inspiration,  as  a  smooth,  rounded, 
blunt,  rather  firm  but  not  hard  siirface. 

The  patient  should  lie  in  either  the  recumbent  or  the  midway 
position  between  the  dorsal  and  right-sided  position.  The  warm 
hands  may  be  applied  in  several  ways :  Ordinarily  one  may  apply  the 
fingers  of  both  hands  close  together  under  the  left  rib  border,  in  the 
midaxillary  line;  thus  moderate  enlargements  may  be  detected,  such 
as  the  acute  splenic  tumor  of  typhoid  fever.  It  is  advisable  in  this 
method  to  draw  the  abdominal  skin  downward  a  little  first,  so  as  to 
palpate  through  as  lax  tissue  as  possible,  and  to  feel  for  the  edge  of 
the  spleen,  especially  at  the  moment  of  fullest  inspiration. 

Probably  the  most  satisfactory  and  reliable  method,  however,  is  to 
palpate  bimanually  by  crossing  hands,  so  that  the  left,  placed  over  the 
normal  position  of  the  spleen,  draws  this  lower  portion  of  the  thorax 
inward  and  downward,  at  the  same  time  sliding  the  skin  loosely 
toward  the  right,  for  the  reason  given  in  describing  the  preceding 
method.  The  right  hand  of  the  examiner  meanwhile  awaits  the 


FIG.  84. — PALPATING  THE  SPLEEN.     (Musser.) 

spleen  by  pointing  straight  up  under  the  rib  border,  and  pressing 
in  a  little  with  the  finger-tips  at  the  end  of  inspiration,  while  the 
pressure  of  the  left  hand  over  the  splenic  region  is  exerted  simul- 
taneously. 

Another  method  is  to  have  the  patient  lie  on  the  right  side,  while 
the  physician  stands  behind  and  crooks  the  fingers  under  the  rib 
margin  and  tries  to  feel  the  spleen  at  the  end  of  a  deep  inspiration. 

Abnormally,  the  spleen  can  be  felt: 


404  PHYSICAL    DIAGNOSIS 

(1)  If  it  is  enlarged. 

(2)  If  it  is  displaced  (wandering  or  floating  spleen). 

(3)  In  certain  cases  of  chest  deformity. 

By  palpation  we  determine  the  size,  shape,  surface,  consistence, 
mobility,  and  position  of  the  spleen.  As  ordinarily  the  spleen  is  pal- 
pable only  when  it  is  enlarged,  it  will  be  appropriate  to  point  out  the 
various  causes  of  enlargement,  and  at  the  same  time  indicate  the 
changes  in  the  other  physical  signs  associated  with  a  given  variety 
of  enlargement.  Most  of  the  enlargements,  especially  those  of  slight 
or  moderate  degree,  are  uniform  in  shape;  and  even  the  majority  of 
the  larger  and  more  chronic  enlargements  have  the  form  of  the 
normal  spleen. 

(a)  Infectious  Febrile  and  Septic  Diseases. — These  cause  slight  or 
moderate  splenic  enlargement,  of  uniform  shape,  smooth  surface,  soft 
or  moderately  firm  consistence,  and  slight  respiratory  mobility.  The 
principal  causes  under  this  head  are  typhoid  fever,  malarial  fever, 
scarlet  fever,  smallpox,  relapsing  fever,  typhus  fever,  erysipelas, 
septicopyemia,  acute  miliary  tuberculosis,  and  epidemic  cerebrospinal 
meningitis. 

(&)  Chronic  Blood  Diseases,  Principally. — Here  there  is  also  uni- 
form enlargement  of  the  spleen,  but  the  size  is  greatly  increased,  the 
surface  likewise  smooth  or  but  slightly  uneven,  the  consistence  hard, 
and  the  mobility  easily  demonstrable  unless  the  enlargement  is  PO 
excessive  as  to  prevent  downward  movement  of  the  diaphragm.  To 
be  enumerated  here  are  the  following:  Chronic  malaria,  chronic  con- 
gestion from  primary  hepatic  cirrhosis,  leukemia,  splenic  anemia, 
Hodgkin's  disease,  amyloid  disease,  tuberculosis,  syphilis,  rickets. 

(c)  Neoplasms,  etc. — The  spleen  is  irregular  in  shape,  moderate 
or  marked  in  enlargement,  uneven  of  surface,  firm,  fluctuating,  or 
boggy  in  consistence,  and  more  or  less  responsive  to  respiratory  move- 
ments. Thus  we  have  cancer,  abscess,  and  hydatids  of  the  spleen. 

In  most  of  the  cases  of  large,  uniform  enlargements  of  the  spleen, 
notches  may  be  felt  along  its  anterior  border. 

Wandering  spleen  may  be  palpated  better  sometimes  by  placing  the 
patient  in  the  knee-chest  position;  the  hilum  may  also  be  felt,  and 
respiratory  mobility  is  diminished,  or  more  often  absent. 

Differential  Diagnosis. — It  is  important  to  distinguish  between 
splenic  enlargement  and  tumor  of  the  left  kidney.  This  will  be 
discussed  in  the  consideration  of  the  latter  organ. 

It  is  possible  sometimes  to  mistake  at  first  a  fecal  mass  in  the 
splenic  flexure  of  the  colon  for  an  enlarged  spleen;  but  the  peculiar 


THE    LIVER,    SPLEEN,    AND    KIDNEYS  405 

doughy  feel  of  the  former,  and  its  removal  by  catharsis  or  enemata, 
as  well  as  the  absence  of  splenic  outlines  and  of  respiratory  and 
passive  mobility,  serve  to  make  the  diagnosis  clear. 

The  occurrence  of  cancer  of  the  cardiac  end  of  the  stomach,  or  of 
an  enlarged  left  lobe  of  the  liver,  should  be  borne  in  mind,  but  hardly 
needs  any  specific  points  of  differentiation  from  splenic  tumor  at  this 
place  other  than  to  mention  that  the  study  of  location,  form,  con- 
sistence, and  mobility  will  usually  suffice  to  decide  in  each  instance, 
associated,  of  course,  with  the  gastric  history  and  symptomatology, 
and  the  results  of  other  methods  of  examination. 


PERCUSSION 

This  method  of  examining  the  spleen  is  of  less  value  than  palpa- 
tion, and  is  only  confirmatory  of  enlarged  spleen  when  this  organ 
has  been  felt  as  such. 

The  normal  splenic  dulness  represents  that  portion  of  the  spleen 
which  is  parietal ;  that  is,  below  and  between  the  inferior  lung  border 
and  the  eleventh  rib.  This  dulness  is  not  extreme  or  flat  in  quality, 
owing  to  the  juxtaposition  of  the  resonant  lung  and  the  tympanitic 
stomach  and  colon.  The  dull  area  varies  slightly  in  position  and 
definiteness  because  of  its  respiratory  and  passive  mobility,  being 
more  posterior  when  the  patient  lies  upon  the  back,  more  anterior 
but  less  dull  when  on  the  right  side  (the  spleen  being  farther  from 
the  ribs) ;  with  the  patient  standing,  however,  the  spleen  is  a  trifle 
lower. 

To  outline  the  splenic  area  of  dulness  by  percussion,  the  subject 
should  lie  on  the  right  side,  midway  between  the  dorsal  and  extreme 
lateral  positions,  with  the  left  arm  elevated.  As  the  dulness  obtained 
is  merely  relative  in  most  cases,  the  percussion  should  be  made  with 
light  strokes  over  the  antero-inferior  portion  (uncovered  by  lung) ; 
posteriorly,  stronger  strokes  are  necessary.  When  the  spleen  is  greatly 
enlarged,  the  dorsal  posture  will  do. 

To  determine  the  upper  border  of  splenic  dulness,  we  begin  by 
noting  the  inferior  lung  limit.  With  moderately  strong  blows  we 
percuss  sufficiently  high  up  in  the  posterior  part  of  the  axillary 
region  to  elicit  good  pulmonary  resonance.  Percussing  thence  down- 
ward, we  note  the  first  evidence  of  slight  elevation  of  pitch  and  rela- 
tive dulness,  then  with  lighter  strokes  continue  downward,  noting 
true  dulness,  until  a  faint  tympanitic  quality  is  perceived.  This 
gives  the  upper  boundary  of  splenic  dulness,  where  relative  passes 


406  PHYSICAL    DIAGNOSIS 

into  nearly  absolute  dulness,  and  also  the  vertical  extent  of  dulness 
along  the  perpendicular  line  of  percussion. 

The  anterior  border  of  splenic  dulness  is  obtained  by  percussing 
from  before  backward  at  the  level  of  and  in  the  direction  of  the 
tenth  rib,  beginning  at  the  costal  margin.  Thus  we  note  where  the 
gastric  tympany  changes  to  splenic  dulness. 

The  inferior  limit  of  splenic  dulness  is  determined  by  percussing 
upward  in  about  the  posterior  axillary  line  until  intestinal  tympany 
merges  into  the  dulness,  which  is  normally  at  the  eleventh  rib. 

The  posterior  limit  seldom  needs  to  be  determined,  and  usually 
cannot  be  satisfactorily,  for  obvious  anatomic  reasons. 

The  size  of  the  area  of  splenic  dulness  is  estimated  ordinarily 
by  its  vertical  extent  in  the  middle  or  posterior  axillary  line,  below 
the  spleen-lung  angle,  where  the  inferior  lung  border  begins  to  over- 
lap the  spleen.  Normally,  this  measiires  on  the  average  about  three 
or  three  and  one-half  inches.  Again,  the  anterior  limit  of  the  splenic 
area  should  not  extend  beyond  the  lined  costo-articularis,  or  the  line 
drawn  from  the  tip  of  the  eleventh  rib  to  the  left  sternoclavicular 
articulation  ( Vierordt ) . 

Variations. — The  area  of  splenic  dulness  may  apparently  be  in- 
creased through  distention  of  the  stomach  with  food,  fecal  masses 
in  the  adjacent  colon,  colloid  cancer  of  the  cardia  of  the  stomach, 
left  pleural  effusion,  pneumonic  consolidation  at  the  left  base,  pleural 
thickening,  or  a  new  growth  of  the  pleura  or  lung. 

On  the  other  hand,  splenic  dulness  is  delimited  with  difficulty 
in  obese  persons,  and  it  is  apparently  decreased  in  size  by  encroaching 
emphysematous  lung,  by  pneumothorax,  tympanites,  and  by  displace- 
ment upward  by  ascites  or  a  large  abdominal  tumor.  Total  absence 
of  splenic  dulness  may  be  due  to  floating  spleen,  which  may  then  be 
palpated  in  its  abnormal  position,  and  recognized  by  its  shape,  mobil- 
ity, notches,  sharp  edge,  and  the  reappearance  of  dulness  in  the  proper 
area  when  the  organ  is  replaced. 

Enlargement  of  the  Splenic  Dulness. — After  eliminating  the  pos- 
sible sources  of  error  mentioned  above  in  connection  with  an  apparent 
increase  of  dulness,  the  examiner  should  note  the  shape  of  the  in- 
creased area  of  dulness,  and  its  position  relative  to  the  adjacent  organs 
and  ribs.  Enlargement  of  the  spleen  may  be  diagnosed  if  the  vertical 
measurement  of  dulness  is  four  inches  or  over,  and  if  the  anterior 
border  of  the  dull  area  extends  beyond  the  linea  costo-articularis. 
In  instances  of  great  enlargement  the  gastric  tympany  may  be  en- 
tirely obliterated. 


PLATE    XI 


SURFACE  PROJECTION  OF  THE  RIGHT  KIDNEY:  ANTERIOR  RELATIONS  OF  SPLEEN. 


THE    LIVER,    SPLEEN,    AND    KIDNEYS 


407 


AUSCULTATION 

A  friction  sound  over  the  splenic  area  may  be  set  up  by  a  plastic 
deposit  upon  the  serous  covering  of  the  spleen  and  the  parietal  por- 
tion of  the  peritoneum  opposite  to  it,  this  sound  corresponding  to  the 
diaphragmatic  movements.  Such  evidence  of  perisplenitis  may  indi- 
cate a  septic  embolus  and  infarct  of  the  spleen,  an  abscess,  or  simply 
an  intense  splenic  congestion  associated  with  a  severe  infectious  fever. 
In  the  marked  cases  of  enlargement,  as  in  leukemia  and  chronic 
malaria  ("  ague-cake  "),  distinct  perisplenic  friction  may  be  heard  not 
infrequently  with  the  stethoscope. 


TOPOGRAPHIC    ANATOMY    OF    THE    KIDNEYS 

These  bean-shaped  organs  lie  against  the  posterior  abdominal  wall, 
one  on  each  side  of  the  spinal  column.  They  are  embedded  in 
fat  as  they  lie  in  their  respective  retroperitoneal  fossae,  upon  the 
quadratus  lumborum 
muscles  and  the  lumbar 
portions  of  the  dia- 
phragm, the  right,  how- 
ever, a  little  lower  than 
the  left — about  |  in. 
Their  lower  ends  diverge 
somewhat,  so  that  they 
are  about  a  finger's 
breadth  farther  from  the 
median  body  line  than 
their  upper  ends.  Each 
kidney  is  about  4  in. 
long,  about  2^  in.  broad, 
and  f  to  1  in.  thick. 
The  upper  border  of  the 
right  kidney  lies  in  con- 
tact with  the  liver,  and 
reaches  the  level  of  the 
eleventh  dorsal  spine ; 

that  of   the   left   kidney,  overlapped   by   the  spleen,  reaches  to  the 
eleventh  rib.    The  lower  end  of  the  left  kidney  coincides  with  the  level 
of  the  third  lumbar  spine;  that  of  the  right  is  |  in.  lower,  or  about 
29 


FIG.  85. — SHOWING  THE  NORMAL  SURFACE  RELA- 
TIONS OF  THE  KIDNEYS  ANTERIORLY,  AND  THE 
METHOD  OF  DETERMINING  THESE  RELATIONS. 
(Butler.) 


408 


PHYSICAL    DIAGNOSIS 


1  in.  above  the  iliac  crest.    Butler's  parallelograms  for  the  location  of 
the  kidneys  topographically  on  the  back  are  admirable. 

Anteriorly,  the  lower  border  of  the  right  kidney  reaches  a  point 
about  1  in.  above  a  horizontal  line  through  the  navel;  that  of  the 
other,  of  course,  1£  in.  above  the  line. 


„,;  Lower  border  of  lungs 
-.  .  Level  of  spine  of  llth 

I      dorsal  vertebra 
'H  Lower  border  of  liver 


Level  of  spine  of  3d  lum- 
bar vertebra 
"1  Tympanitic  colon 


FIG.  86. — SHOWING  SURFACE  RELATIONS  OF  KIDNEYS  POSTERIORLY;  ALSO  THE  COM- 
BINED PERCUSSION  DULNESS  (SHADED  AREA)  OF  LIVER,  SPLEEN,  KIDNEYS,  AND 
THICK  MUSCLES  OF  THE  BACK;  ALSO  THAT  IF  THE  COLON  is  EMPTY  OF  FECES  AND 
DISTENDED  WITH  GAS  THE  LOWER  AND  A  PART  OF  THE  OUTER  BORDER  OF  THE 
KIDNEY  CAN  BE  OUTLINED  BY  PERCUSSION.  Lines  of  percussion  indicated  by 
arrows  on  right  kidney.  (Butler.) 

The  ascending  and  descending  portions  of  the  colon  lie  in  front 
of  the  kidneys,  and  the  inner  border  of  the  right  kidney,  at  its  an- 
terior surface,  is  quite  near  the  common  bile  duct  and  duodenum. 


EXAMINATION    OF   THE    KIDNEYS 

INSPECTION 

The  normal  kidney  cannot  be  inspected,  and  only  when  a  large 
tumor  of,  or  a  superficially  floating,  kidney  occurs  is  it  possible  to 
see  some  external  evidence  of  the  organ.  The  kidney  is  most  visible 


THE    LIVER,    SPLEEN,    AND    KIDNEYS  409 

when  it  is  at  once  enlarged  and  displaced.  It  is  then  usually  seen 
in  either  flank,  in  the  waist  line,  or  even  lower  down.  The  most 
common  causes  of  renal  tumor  with  bulging  in  the  anterolateral  lum- 
bar region  are  sarcomas  in  children,  and  cystic  or  hydronephrotic 
growths  in  adults.  They  are  usually  not  movable  with  respiration. 
Sometimes  a  perinephric  abscess  may  be  inferred  by  the  discovery  of 
a  roundish,  shiny,  edematous-looking  swelling  in  either  renal  region. 


PALPATION 

This  is  certainly  the  most  informing  method  of  examining  the 
kidneys  physically.  Normally,  it  is  possible  to  palpate  them  bimanu- 
ally  in  some  children,  and  in  those  with  thin,  lax  abdominal  walls, 
especially  during  inspiration. 

Technic. — One  way  to  palpate  the  kidneys  is  to  have  the  patient 
in  the  dorsal  position,  with  slight  flexure  of  the  whole  frame,  from 
head  to  heels.  Then,  with  one  hand  pressing  firmly  forward  into  the 
loin,  and  with  the  other  pressing  deeply  (finger-tips,  palmar  surface) 
in  front,  near  the  midclavicular  line,  one  may  feel  the  enlarged  or 
displaced  kidney  slip  between  the  fingers  as  a  "  greasy  mass,"  to  and 
fro,  during  inspiration  and  expiration.  This  mode  of  palpation  is 
usually  most  satisfactory  in  the  transverse  line,  which  connects  the 
inner  portions  of  the  waist  curves.  A  movable  kidney  may  thus  be 
grasped  for  one-half  or  more  of  its  length,  and  popped  back  during 
expiration.  In  extreme  cases  the  kidney  may  be  palpated  throughout 
its  whole  length  ("floating  kidney"). 

Another  favorite  method  with  many  is  to  attempt  to  grasp  the 
kidney  while  the  patient  stands  and  leans  slightly  forward,  with  the 
hands  resting  upon  a  chair  or  table;  in  this  position  the  abdominal 
walls  are  relaxed,  and  the  kidneys  fall  forward.  In  either  the  re- 
clining or  standing  posture  one  may  also  palpate  the  movable  kidney 
at  times  with  one  hand,  by  grasping  the  soft  part  of  the  flank,  the 
thumb  pressing  under  the  costal  margin  while  the  fingers  press  for- 
ward from  behind.  With  a  deep  inspiration  a  movable  kidney  may 
be  felt  to  slip  downward  within  the  grip,  squeezed  gently  (often 
causing  a  sickening  sensation),  and  then  slip  upward  with  expiration, 
or  be  pushed  up  under  the  seizure. 

Besides  movable  kidney — which,  of  course,  may  have  its  normal 
shape,  more  readily  palpable  because  there  is  usually  a  deficiency  of 
surrounding  fat  in  such  cases — there  are  the  various  enlargements  of 
the  organ, 


410  PHYSICAL    DIAGNOSIS 

Slight  or  moderate  enlargements  are  not  palpable  unless  the  kidney 
is  at  the  same  time  displaced.  These  include  such  affections  as  renal 
engorgement,  chronic  nephritis  ("large  white  kidney"),  and  amy- 
loid kidney. 

Large  renal  tumors  are  difficult  to  diagnose,  because  of  their  pro- 
trusion forward  and  simulation  of  other  abdominal  organs  adjacent. 
The  following  enlargements  of  the  kidney  are  palpable  without  its 
dislocation:  Malignant  disease,  sarcoma  more  often  than  carcinoma; 
cystic  degeneration ;  hydronephrosis ;  pyonephrosis,  including  tubercu- 
losis; echinococcus  disease,  and  perinephric  abscess. 

These  tumors  are  felt  to  occupy  the  ordinarily  soft  hollow  of  the 
loin,  sometimes  extending  anteriorly  nearly  as  far  as  the  umbilicus, 
and  filling  completely  the  space  between  the  costal  margin  and  the 
crest  of  the  ilium,  as  in  a  case  of  sarcoma  which  I  saw  in  a  child 
of  eleven  years,  and  one  of  cystic  disease  of  the  left  kidney  in  a  young 
woman.  Sarcomata  in  children  are  especially  large  tumors  as  affect- 
ing the  kidney. 

The  new  growths  are  usually  firm  in  consistence,  and  give  the 
kidney  an  irregular  shape  and  uneven  surface.  With  hydro-  and 
pyonephrosis,  however,  the  outline  is  round  and  smooth,  and  deep 
fluctuation  may  be  elicited;  likewise  with  hydatids,  if  the  cysts  are 
sufficiently  large.  Eenal  tumors  are  but  slightly,  if  at  all,  influenced 
by  the  respiratory  movements,  and  the  absence  of  descent  with  in- 
spiration in  the  case  of  a  large  tumor  in  either  flank  points  to  the 
kidney  rather  than  to  splenic  or  hepatic  involvement.  With  the  peri- 
nephric abscess  there  is  a  boggy  resistance  over  the  region  of  the 
kidney.  In  tumors  of  moderate  size,  as  in  certain  cases  of  cystic 
disease,  the  shape  of  the  kidney  may  be  preserved  to  a  degree,  with 
rounded  edge,  and  a  sort  of  ballotement  phenomenon  may  be  detected 
by  bimanual  palpation.  An  important  aid  in  the  diagnosis  of  renal 
tumors  is  the  relation  of  the  colon,  and  often  the  small  intestine, 
which  may  be  felt  and  percussed,  thus  showing  that  they  are  in  front ; 
while,  on  the  other  hand,  splenic  tumors  especially,  and  hepatic  tu- 
mors usually,  do  not  have  bowel  between  them  and  the  abdominal  wall. 
In  cases  of  doubt,  the  colon  may  be  inflated  with  air  per  rectal  tube 
with  bulb  attachment. 

PERCUSSION 

Although  a  less  useful  source  of  information  as  to  the  physical 
status  of  the  kidney  than  palpation,  nevertheless  percussion  is  too 
often  neglected  when  additional  and  confirmatory  results  may  be 


THE    LIVER,    SPLEEN",    AND   KIDNEYS  411 

acquired.  Some  years  ago  I  percussed  the  renal  region  of  a  series 
of  normal  individuals,  with  a  view  to  determining  the  areas  of  dul- 
ness,  and  in  practically  all  except  the  stout  persons  these  areas  could 
be  fairly  well  outlined,  especially  their  upper  and  outer  borders;  the 
lower  borders  could  be  outlined  less  easily  and  frequently,  and  the 
inner  borders  not  at  all  on  account  of  the  thickness  of  the  spinal 
muscles. 

As  pointed  out  above,  percussion  aids  in  deciding  that  an  abdom- 
inal tumor  is  renal,  depending  upon  the  relation  of  the  colon  to  it. 

Increased  area  of  renal  dulness  indicates  enlargement  of  the  kid- 
ney, particularly  if  it  extends  from  the  spine  to  the  iliac  crest  as 
far  forward  as  the  midaxillary  line.  Enlarged  dull  area,  with  boggy 
swelling,  redness,  and  tenderness,  would  indicate  perinephric  abscess. 

Absence  of  renal  dulness  on  one  side,  replaced  by  tympanitic  clear- 
ness, would  be  confirmatory  of  displaced  kidney,  especially  if  there  is 
a  palpable  tumor  on  the  affected  side  anteriorly.  The  presence  of 
ascitic  fluid  would  prevent  the  determination  of  renal  dulness  or 
floating  kidney. 

Te  clinic. — In  lean  individuals,  even  while  standing,  one  may  per- 
cuss the  kidneys  at  times  with  comparative  ease;  but  more  assured 
success  is  obtained  by  having  the  patient  lying  face  downward,  with 
a  firm  pillow  or  cushion  under  the  belly  to  hold  the  kidneys  against 
the  back  and  better  relax  the  spinal  muscles.  Strong  strokes  are 
required,  and  it  is  frequently  better  to  use  a  plexor  and  pleximeter. 

We  begin  by  percussing  downward  on  a  line  midway  between  the 
scapular  and  midspinal  lines,  and  noting  where  lung  resonance  ends 
and  renal  dulness  begins.  Also,  we  map  out  the  inferior  extremity 
of  the  organs  where  tympanitic  sound  ends  in  percussing  upward  from 
the  crest  of  the  ilium.  Likewise,  the  outer  border  of  the  renal  dul- 
ness is  found  where  tympany  (colon)  passes  into  dulness.  The  upper 
boundary  of  renal  dulness  on  the  right  side  naturally  is  conjoined 
with  the  lower  border  of  liver  dulness,  which  does  not  extend  below 
the  eleventh  rib,  however,  in  the  normal  individual.  Enlargement 
of  either  organ,  therefore,  so  far  as  percussion  is  concerned,  may  be 
determined  by  noting  the  position  of  the  liver-kidney  angle  of  dul- 
ness, whether  down  and  out  beyond  the  normal  or  not.  Similarly, 
the  spleen-kidney  angle  may  be  significant. 

Differential  Diagnosis. — Tumors  of  the  gall-bladder  have  already 
been  discussed  in  connection  with  displaced  right  kidney. 

Splenic  tumors  differ  from  renal  tumors  in  that  the  former  are 
more  superficial  and  in  closer  contact  with  the  anterior  abdominal 


412 


PHYSICAL   DIAGNOSIS 


wall,  advancing,  as  they  increase  in  size,  obliquely  Inward  or  beyond 
UK-  umbilicus;  they  also  present  usually  a  smoother,  harder  surface, 
and  a  sharp  anterior  edge  with  the  characteristic  notches.  Renal 


Flatness 


FIG.  87. — TUMOR  OF  SPLEEN.  X  Reso- 
nance between  the  posterior  margin 
and  the  lumbar  muscles.  (Le  Fevre.) 


FIG.  88. — TUMOR  OF  THE  LEFT  KIDNEY. 
(Le  Fevre.) 


tumors  do  not  maintain  the  shape  of  the  kidney;  are,  in  fact,  less 
likely  to  be  uniform  enlargements  of  this  organ;  they  fill  the  flank 
and  curve  of  the  back  more  especially,  and  the  inflated  colon  is 
demonstrably  (percussion)  in  front  of  them. 

Moderate  enlargements  of  the  spleen  and  wandering  spleen  may 
be  differentiated  from'  floating  Tcidney  by  the  following  points:  In 
the  first  place,  the  left  kidney  is  seldom  found  displaced,  and  hence 
a  tumor  on  the  left  side  is  presumptive  evidence  in  favor  of  splenic 
tumor.  Secondly,  the  palpable  differences  of  form  already  noted, 
the  hilum  of  the  kidney  and  the  notches  of  the  spleen.  Thirdly, 
respiratory  mobility  favors  the  spleen.  Fourthly,  the  percutory  re- 


THE    LIVER,    SPLEEN,    AND    KIDNEYS 


413 


lations  of  the  colon,  and  the  results  of  percussion  over  the  splenic 
and  renal  areas.  If  the  tumor  is  replaceable,  it  speaks  rather  of 
movable  kidney.  Finally,  a  visible  or  palpable  depression  and  yield- 
ing in  the  region  of  the  eleventh  and  twelfth  ribs  may  indicate  dis- 
placed kidney. 

Associated  with  wandering  kidney  frequently,  and  thus  having 
diagnostic  clue,  are  the  physical  signs  of  general  displacement  of  the 
abdominal  organs  —  splanclinoptosis,  or  Glenard's  disease;  sometimes, 
also,  of  dilation  of  the  stomach,  prolapse  of  the  generative  organs, 
and  various  "  skeletal  stigmas,"  such  as  a  tendency  to  or  the  actual 
presence  of  spinal  curvatures,  hernias,  dislocations  of  joints,  pedal, 
and  thoracic  deformities,  etc. 

Obviously,  in  connection  with  all  renal  physical  examinations 
much  definitive  aid  and  confirmation  are  obtained  by  the  results  of 
clinical  chemistry  and  microscopy. 


PART    III 

THE    RONTGEN   RAY   IN   MEDICAL 
DIAGNOSIS 


CHAPTER    XIX 

THE  RONTGEN  RAY  IN  MEDICAL  DIAGNOSIS 
By  G.  E.  PFAHLER,  M.D. 

THE  increased  field  of  usefulness  of  the  Rontgen  ray,  and  its 
increased  accuracy  in  medical  diagnosis  render  a  work  upon  Physical 
Diagnosis  incomplete  without  at  least  a  chapter  upon  the  subject. 

Two  objects  have  been  kept  in  mind  in  the  preparation  of  this 
chapter.  First,  we  desire  to  acquaint  the  general  practitioner  and 
the  student  with  what  may  be  expected  from  the  X-ray  as  an  assist- 
ance in  making  a  diagnosis.  Second,  the  general  technic  and  direc- 
tions for  making  the  examinations  are  given  to  assist  those  who  are 
already  partially  familiar  with  Rontgen  work.  A  complete  description 
of  the  technic  of  Rontgenology  would  require  too  much  space,  and 
would  be  out  of  place  in  a  work  of  this  kind.  A  special  effort  has 
also  been  made  to  give  directions  that  will  assist  the  physician  in 
the  interpretation  of  Rontgen  negatives. 

The  subjects  treated  will  be  those  belonging  purely  to  internal 
medicine,  and  will  consist  of  a  study  of  the  thoracic  and  abdominal 
viscera. 

THE  RELATIVE  VALUE  OF  RONTGENOSCOPY 
AND  RONTGENOGRAPHY 

The  fluoroscopic  screen  renders  valuable  assistance  in  diagnosis. 
It  can  be  used  by  those  who  are  less  familiar  with  the  general  tech- 
nic of  Rontgen  work.  It  is  less  expensive  than  the  making  of  a 
Rontgenogram.  It  enables  the  physician  to  study  the  movements  of 
the  organs.  Finally,  it  enables  him  to  study  the  organs  from  various 
positions,  and  to  get  his  results  quickly.  In  order  to  make  Ront- 
genoscopic  examinations  successfully,  it  is  necessary  to  make  them 
in  a  darkened  room,  and  the  physician  should  spend  from  five  to  ten 
minutes  in  the  dark  room  before  beginning  the  examination,  so  that 
his  eyes  will  be  in  condition  to  appreciate  delicate  shadows. 

417 


418  PHYSICAL   DIAGNOSIS 

Rontgenoscopy,  however,  has  several  disadvantages.  It  requires 
an  exposure  of  several  minutes,  and  at  times  a  half-hour,  until  the 
physician  satisfies  himself  and  those  around  him  concerning  the  vari- 
ous shadows.  This  at  once  makes  the  Rontgen  rays  a  serious  danger 
to  the  patient,  and  a  very  grave  danger  to  the  operator,  because  of 
the  many  repetitions  of  these  exposures  in  the  examination  of  many 
patients.  The  danger  to  the  operator  is  a  troublesome  dermatitis, 
the  loss  of  hair  and  nails,  and,  as  has  been  more  recently  shown,  the 
danger  of  the  production  of  sexual  sterility.  This  has  led  the  older 
and  more  experienced  Rontgenologists  to  abandon,  or  at  least  limit, 
Rontgenoscopic  examinations.  These  prolonged  examinations  are  also 
a  great  wear  upon  the  tubes  and  the  apparatus,  and  therefore  more 
or  less  expensive. 

Rontgenography  has  many  advantages.  With  good  technic  and  a 
good  apparatus,  a  Rontgenogram  can  be  made  of  any  part  of  the  body 
in  from  one  second  to  one  minute.  It  is  practically  impossible  to  do 
the  patient  harm  in  this  short  time.  During  this  examination  the 
operator  can  work  behind  screens.  We  therefore  avoid  at  once  the 
most  serious  objection  found  in  screen  examinations.  The  plate  forms 
a  most  accurate  and  permanent  record,  which  can  be  demonstrated 
to  others,  or  can  be  referred  to  at  any  time  in  the  study  of  the  progress 
or  cure  of  the  disease.  Organs  can  be  studied  from  various  positions 
by  making  several  plates.  The  records  will  then  be  permanent,  and 
can  be  used  for  more  detailed  study.  The  most  important  advantage, 
however,  of  the  Rontgenogram  is  the  great  improvement  in  detail  and 
accuracy.  Shadows  which  cannot  be  seen  at  all  upon  the  screen  will 
appear  clearly  upon  the  plate.  This  increase  in  detail  and  accuracy 
will  easily  repay  the  extra  cost  of  time  and  money,  and  is  to  be 
recommended  always,  even  when  a  fluoroscopic  examination  has  been 
made. 

GENERAL  TECHNIC  OF  RONTGENOGRAPHY 
OF  THE  CHEST 

As  a  rule,  Rontgenograms  of  the  chest  are  best  made  with  the 
patient  in  the  recumbent  position.  The  supine  or  the  prone  position 
may  be  used.  If  the  lesion  to  be  especially  studied  is  nearer  the 
posterior  wall,  the  supine  position  should  be  used.  If  the  lesion  is 
nearer  the  anterior  wall,  the  prone  position  is  to  be  preferred.  If 
time  and  expense  are  not  considerations,  both  positions  should  be  used 
in  each  case.  The  hands  should  be  clasped  over  the  head.  This 


THE    BONTGBN    RAY    IX    MEDICAL    DIAGNOSIS     419 

throws  the  scapula  out  of  the  way,  and  leaves  the  lateral  wall  of  the 
chest  clear.  When  fluids  within  the  chest  are  to  be  examined,  the 
patient  should  be  placed  in  the  upright  position. 

The  plate  should  be  placed  beneath  or  posterior  to  the  patient, 
and  the  tube  should  be  placed  at  a  distance  of  from  16  to  20  in.  (40 
to  50  cm. ) .  Ordinarily,  the  tube  should  be  placed  in  the  median  line, 
on  a  level  with  the  nipples.  A  14  X  17-in.  plate  will  usually  record 
the  whole  chest  cavity  and  the  shoulders. 

The  time  of  exposure  will  vary  with  the  organ  under  examination. 
If  the  lungs  are  being  studied,  the  exposure  should  be  from  five  to 
twenty  seconds,  or  during  the  time  that  the  patient  can  hold  the 
breath.  There  are  few  patients  needing  an  X-ray  examination  who 
can  hold  their  breath  longer  than  twenty  seconds,  and  few  who  cannot 
hold  it  five  seconds.  A  few  Rontgenograms  have  been  made  in  a 
second  or  less,  but  this  cannot  be  depended  upon  as  a  working 
basis. 

The  ability  of  the  patient  to  hold  the  breath  should  be  carefully 
tested  beforehand.  The  time  will  be  found  to  increase  after  a  few 
efforts.  This  test  will  enable  the  operator  to  estimate  the  time  of  the 
exposure,  and  will  give  the  patient  confidence. 

Rontgenograms  of  the  chest  made  in  the  fraction  of  a  second 
require  the  most  favorable  circumstances,  and  even  then  the  shadows 
are  weak  and  indistinct.  Therefore,  the  heart  cannot  be  photographed, 
as  a  rule,  in  the  resting  position.  Usually  all  of  the  organs  of  the 
chest  can  be  photographed  in  from  five  to  twenty  seconds.  If  the 
internal  structure  of  an  aneurism  or  of  the  vertebra  is  to  be  studied, 
the  exposure  may  have  to  be  prolonged. 

The  vacuum  of  the  tube  should  be  medium.  That  is,  it  should 
equal  the  resistance  of  a  parallel  spark-gap  of  from  2£  to  3  in.  (6  to 
8  cm.)  in  the  open  air. 

The  amount  of  current  should  be  as  great  as  can  be  forced  through 
the  tube. 

Smaller  sections  of  the  chest  may  be  examined  and  greater  detail 
obtained  by  making  use  of  the  diaphragm  technic. 

Rontgenoscopy  of  the  Chest. — If  a  Rb'ntgenoscopie  examination 
be  made,  the  detail  can  also  be  improved  by  making  use  of  a  dia- 
phragm, which  will  exclude  all  of  the  unnecessary  rays.  A  protective 
fluoroscope,  and  protecting  gloves  and  apron,  should  be  used  by  the 
operator. 

Appearances  of  the  Normal  Thorax  (Plate  XII,  A). — Whether  the 
physician  uses  the  Rontgen  ray  as  a  part  of  his  daily  work,  or  whether 


420  PHYSICAL    DIAGNOSIS 

he  only  uses  it  occasionally,  or  whether  he  depends  entirely  upon 
some  one  else  for  his  work,  it  is  necessary  that  he  should  become 
familiar  with  the  normal  appearances  of  the  various  parts  of  the 
body.  Until  he  has  done  this  he  cannot  appreciate  the  pathologic 
lesions,  even  when  they  are  pointed  out  to  him. 

If  a  screen  examination  is  being  made,  the  most  striking  shadow 
will  be  that  of  the  diaphragm  rising  and  falling  with  each  respiration. 
The  average  normal  excursion  of  the  diaphragm  has  been  found  by 
Williams  ("The  Bontgen  Rays  in  Medicine  and  Surgery,"  1903)  to 
be  6.8  cm.  on  the  right  side  and  7.1  cm.  on  the  left  side,  between 
forced  inspiration  and  forced  expiration.  The  average  normal  ex- 
cursion during  quiet  breathing,  however,  was  found  to  be  about  1.5 
cm.  In  the  Bontgenograph,  the  shadow  of  the  diaphragm  will  be 
found  resting  on  a  level  with  the  tenth  rib,  or  between  the  ninth 
and  tenth,  in  the  midscapular  line,  providing  the  patient  holds 
his  breath  during  the  rest  between  inspiration  and  expiration.  This 
is  the  best  position  in  which  to  hold  the  breath  for  radiographic 
purposes. 

The  next  striking  shadow  will  be  that  of  the  pulsating  hcnrt, 
which  is  a  triangular  shadow  in  the  lower  middle  portion  of  the  chest, 
and  extending  toward  the  left.  In  the  Eontgenogram,  this  shadow 
is  found  to  extend  about  4.5  cm.  to  the  right  of  the  median  line, 
and  about  11  cm.  to  the  left  of  the  median  line.  This  will  vary 
somewhat  with  the  size  of  the  patient,  and  therefore  with  the  normal 
size  of  the  heart. 

Having  observed  the  shadows  of  the  spinal  column,  the  thoracic 
and  shoulder  bones,  we  are  then  prepared  to  study  the  more  delicate 
shadows  of  the  structure  of  the  lungs.  When  making  observations 
with  the  fluoroscope,  we  are  struck  by  the  marked  transparency,  and 
both  sides  should  be  equally  clear.  In  the  Eontgenograph,  however, 
we  may  observe  some  of  the  structure  of  the  lung.  We  usually  detect 
shadows  which  are  more  dense  in  the  region  of  the  large  pulmonary 
vessels.  In  exceptionally  clear  negatives  we  may  see  branches  and 
subbranches  (Plate  XII,  B).  The  transparency  about  the  apices  will 
be  somewhat  modified  by  the  muscles  of  the  shoulder,  and  this  modi- 
fication will  vary  with  the  amount  of  muscle.  In  general,  the  clear- 
ness of  the  image  will  be  diminished  in  proportion  to  the  amount 
of  fat,  muscle,  or  edema  of  the  chest  walls. 

In  the  upper  portion  of  the  mediastinum  the  shadow  of  the  arch 
of  the  aorta,  and  less  clearly  those  of  the  innominate  and  carotid 
arteries,  may  be  seen. 


THE    ROXTGEX    RAY    IX    MEDICAL    DIAGNOSIS     421 

TECHNIC    OF    RONTGENOGRAPHY    IN    PATHOLOGIC 
CONDITIONS    OF    THE    CHEST 

THE   LUNGS 

Pulmonary  Tuberculosis. — One  of  the  most  important  applications 
of  the  Rontgen  rays  in  internal  medicine  is  that  of  aiding  in  the 
diagnosis  of  pulmonary  tuberculosis.  N"o  degree  of  skill  in  the  appli- 
cation of  physical  diagnosis  can  compete  with  the  rays  in  determining 
and  recording  with  accuracy  the  plane  location  of  various  patho- 
logic lesions.  Yet  each  has  a  distinct  value  of  its  own,  which  can- 
not be  replaced.  Each  case,  if  possible,  should  be  carefully  studied 
by  both  physical  and  Rontgen  examination.  As  a  rule,  a  careful 
physical  examination  should  precede  the  Rontgen  examination,  not 
because  it  will  modify  the  shadows,  but  because  it  will  enable  the 
physician  to  interpret  those  present,  may  modify  the  method  of  exam- 
ination, and  thus  make  a  second  examination  unnecessary. 

CASES  ix  WHICH  THIS  EXAMINATION  Is  INDICATED. — No  case 
is  thoroughly  studied  without  this  examination.  It  is  particularly 
indicated  in  early  or  doubtful  cases.  It  should  be  our  aim  to  make 
the  diagnosis  in  the  prebacillary  stage  (before  bacilli  appear  in  the 
sputum),  or  even  in  the  presputal  stage  (H.  S.  A.),  and  here  the  rays 
will  be  of  the  greatest  assistance.  In  favorable  cases  the  earliest 
possible  lesions  can  be  shown;  that  is,  during  the  stage  of  congestion 
(Plate  XII,  B).  It  is  also  important  to  use  the  rays  to  make  an 
accurate  record,  and  estimate  the  progress  or  cure  of  the  disease.  Old 
calcified  tubercles,  old  scars,  consolidations,  abscesses,  cavities,  em- 
physema, gangrene,  thickened  pleura,  pleural  effusion,  pneumothorax, 
and  enlarged  mediastinal  glands  may  he  observed. 

INTERPRETATION. — The  proper  interpretation  of  a  negative  is  as 
important  and  as  difficult  as  the  making  of  it.  The  negative  itself 
should  be  used,  when  possible,  for  study,  since  many  of  the  finer 
shadows  are  lost  in  the  printing. 

Old  calcified  tubercles  give  the  most  decided  shadow,  and  lesions 
of  this  kind  can  be  recognized  as  small  as  3  mm.  in  diameter 
(Plate  XIII,  A  andB). 

Old  scars  or  fibrous  tissue  cast  a  less  dense  shadow,  and  require 
larger  lesions,  but  they  can  usually  be  recognized  by  their  bandlike 
appearances  (Plate  XIII,  B). 

Consolidations  vary  in  the  density  of  their  shadows  with  the  size 
of  the  lesion,  but  an  area  1  cm.  in  diameter  can  be  recognized  in  an 


422  PHYSICAL    DIAGNOSIS 

emaciated  person  (Plate  XII,  B,  and  XIII,  A).  Consolidations  sel- 
dom occur  singly,  therefore  they  give  the  lung  a  mottled  appearance 
(Plate  XIV,  A  and  B),  except  when  there  is  massive  consolidation 
(Plates  XIV,  B,  XV,  A  and  B,  XVI,  A).  Finally  the  consolidation 
can  be  recognized  by  comparison  of  the  suspected  area  with  that  of 
the  opposite  lung,  or  with  the  other  parts  of  the  same  lung.  The 
tuberculous  deposits,  or  the  affected  areas  lying  in  different  planes, 
are  thrown  upon  the  plate  in  one  plane.  Therefore,  upon  superficial 
observation,  one  might  conclude  that  a  greater  proportion  of  the  lung 
is  affected  than  is  correct.  That  is,  the  whole  lung  might  show  a 
mottled  appearance,  and  the  false  conclusion  be  drawn  that  no  healthy 
lung  tissue  remained.  This  mistake  need  not  be  made  by  an  ex- 
perienced observer,  because,  if  the  whole  lung  or  lobe  is  affected,  the 
degree  of  general  density  will  be  much  greater  than  when  only  scat- 
tered areas  are  involved,  and  the  density  will  approach  that  of  the 
shadow  of  the  heart  (Plates  XIV,  B,  XV,  A  and  B,  XVI,  A).  Even 
when  a  whole  lobe  or  lung  is  involved,  the  shadow  is  rarely  uniformly 
dense,  because  the  lung  is  rarely  uniformly  consolidated  (Plate 

XVI,  A).     There  are  likely  to  be  small  or  large  areas  of  cavity  or 
compensatory  emphysema  associated. 

Cavities  are  usually  recognized  by  their  increased  transparency, 
surrounded  by  the  shadow  of  consolidation  (Plates  XVI,  B,  and 

XVII,  A).     If  the  cavity  is  large,  there  will  be  little  difficulty  in 
recognizing  it.     If,  however,  the  cavity  is  small,  or  is  resting  upon  a 
large  area  of  consolidation  or  thickened  pleura,  it  is  less  easily  recog- 
nized.    Under   favorable    circumstances,    a    cavity    1.5    cm.    can   be 
recognized. 

Emphysematous  areas  are  also  noticeably  transparent.  A  dense 
shadow  may  be  found  on  one  side  of  this  area,  but  it  is  likely  to  have 
the  other  side  continuous  with  more  or  less  healthy  tissue,  and  there- 
fore can  be  differentiated  from  a  cavity  (Plates  XV,  B,  XVII.  A, 

XVIII,  A). 

Pulmonary  Abscess. — This  diagnosis  cannot  be  entirely  made  by 
means  of  the  Eontgen  ray,  but  when  it  is  suspected  it  can  be  more 
accurately  localized  by  the  assistance  of  the  rays.  The  radiographic 
appearances  will  not  differ  materially  from  those  of  a  cavity,  except 
that  the  surrounding  area  of  consolidation  is  likely  to  be  larger  in 
proportion  to  the  size  of  the  cavity  (Plates  XVII,  B,  and  XVIII,  A). 
Since  the  two  may  be  associated,  however,  the  difficulties  are  increased, 
and  the  findings  must  be  carefully  compared  with  the  physical  signs 
before  operating. 


THE    ROXTGEX    EAY    IX    MEDICAL    DIAGNOSIS     423 

Pulmonary  Gangrene. — The  remarks  made  above  in  connection 
with  pulmonary  abscess  will  apply  to  pulmonary  gangrene,  except 
that,  instead  of  the  area  of  consolidation  being  large  and  the  cavity 
small,  the  cavity  is  more  likely  to  be  large  and  the  surrounding  wall 
small.  The  conditions  and  the  shadows  will  vary  with  the  stage  at 
which  the  examination  is  made.  The  odor  will  usually  suggest  the 
diagnosis,  and  the  rays  will  be  useful  in  locating  the  area  for  opera- 
tion (Plates  XVIII,  B,  and  XIX,  A). 

Pneumonia. — The  fluoroscope  shows  a  dense  shadow  in  the  affected 
area,  and  the  movements  of  the  diaphragm  are  diminished  on  the 
affected  side,  partly  because  of  the  increased  density  of  the  lung  and 
partly  at  times  because  of  an  adhesive  pleurisy.  Williams  was  one 
of  the  first  to  apply  the  rays  in  the  study  of  pneumonia.  He  de- 
pended almost  entirely  upon  the  fluorescent  screen.  It  is  also  a  most 
useful  adjunct  in  the  diagnosis  of  lesions  not  centrally  located,  espe- 
cially when  such  lesions  are  situated  beneath  the  scapula,  or  when 
small  consolidations  are  surrounded  by  areas  of  compensatory  emphy- 
sema. Compensatory  emphysema  assists  in  outlining  the  lesions  by 
means  of  the  Rontgen  ray  because  of  its  greater  transparency,  but 
offers  considerable  hindrance  when  physical  signs  are  depended  upon. 
De  la  Camp  found  even  in  lobar  pneumonia  that  the  whole  lobe  is 
seldom  uniformly  consolidated,  and  he  often  found  by  means  of  the 
rays  extension  of  the  process  in  another  lobe  or  in  the  opposite  lung, 
when  ordinary  physical  examination  failed  to  reveal  such  lesions. 

He  also  found  the  rays  of  great  assistance  in  the  study  of  the 
cases  during  resolution.  In  some  cases,  months  were  required  for  the 
lung  to  completely  recover.  The  rays  show  lesions  long  after  the 
physical  signs  are  negative.  In  one  case,  in  which  the  patient  com- 
plained of  pain  in  the  region  of  the  heart,  which  persisted  four 
months  after  the  crisis  and  after  all  physical  signs  were  negative, 
the  Rontgen  examination  showed  a  fibrous  band,  about  0.5  cm.  broad, 
binding  the  left  side  of  the  diaphragmatic  pleura  to  the  pericardial 
sac.  Other  symptoms  of  obscure  origin  following  pneumonia  may 
often  be  cleared  up  by  the  aid  of  a  Rontgen  examination.  The  same 
principles  that  have  been  described  in  the  interpretation  of  tuberculous 
negatives  will  apply  to  those  of  pneumonia.  The  areas  involved, 
however,  are  usually  larger,  and  therefore  more  easily  recognized 
(Plate  XV,  A). 

Emphysema. — In  a  typical  case  of  emphysema,  one  is  struck  by 
the  great  transparency,  which  is  greater  than  in  any  other  condition 
of  the  lungs.  This  transparency  affects  both  lungs.  The  ribs  will 
30 


424  PHYSICAL    DIAGNOSIS 

be  found  to  extend  outward  from  the  spinal  column  at  more  nearly 
a  right  angle  than  normal.  To  distinguish  the  lesser  grades  of  em- 
physema, or  to  recognize  local  areas,  much  more  experience  is  neces- 
sary. For  then  one  must  keep  in  mind  the  normal  Rb'ntgenograna 
of  a  patient  of  the  same  age  and  general  development,  thickness  of 
the  chest  walls,  etc.,  and  made  under  similar  conditions  (see  Com- 
pensatory Emphysema). 

Collapse  of  the  Lung. — Collapse  of  the  lung  will  probably  not  be 
recognized  by  means  of  the  Rontgen  rays  when  the  area  involved  is 
small,  but  when  the  area  is  large  it  gives  an  appearance  very  similar 
to  consolidation.  It  is  more  uniform  and  more  sharply  outlined  than 
tuberculosis,  and  it  involves  a  lesser  area  than  when  pneumonic  con- 
solidation is  present. 

THE  PLEURA 

Thickened  Pleura. — Thickening  of  the  pleura  is  a  common  affec- 
tion, occurring  both  independently  and  in  association  with  tubercu- 
losis of  the  lung.  This  condition  is  recognized  in  the  Rontgenogram 
as  a  uniform  shadow  of  only  slight  density.  The  density  will  vary 
with  the  degree  of  thickening.  This  shadow  is  then  seen  to  shade 
gradually  at  its  edge  into  the  surrounding  clear  space.  If  the  sur- 
rounding lung  is  healthy,  there  will  be  little  difficulty  in  recognizing 
a  moderate  thickening.  If,  however,  the  thickened  pleura  is  over- 
shadowed by  consolidation  of  the  lung,  it  becomes  more  difficult,  and 
at  times  impossible.  Here  experience  alone  will  serve  as  a  guide. 
In  order  to  study  the  pleura  accurately,  both  an  anterior  and  posterior 
plate  should  be  made  (Plates  XIX,  B,  XIII,  A,  XVII,  A). 

Pleural  Effusion. — Pleural  effusion  is  best  recognized  by  placing 
the  patient  in  the  erect  posture,  with  the  plate  or  screen  posteriorly 
and  the  tube  anteriorly.  To  make  a  Rontgenogram  :  Place  the  patient 
in  a  chair,  with  a  large  board  resting  against  the  back,  and  upon 
which  the  plate  is  supported.  The  pleural  effusion  gives  a  uniform 
but  not  very  dense  shadow,  occupying  the  lower  part  of  the  pleural 
cavity.  The  upper  level  of  the  shadow  has  a  curved,  but  not  an 
irregular,  line.  In  uncomplicated  effusion,  the  shadow  is  even  more 
uniform  than  that  of  a  thickened  pleura.  Pleural  thickening  will 
also  be  recognized  by  its  irregular  border,  which  is  never  a  line.  The 
shadow  is  less  dense  than  would  be  produced  by  the  consolidation 
of  the  lobe  of  lung  (Plate  XX,  A). 

Pneumothorax  is  recognized  by  the  area  of  great  transparency 
(greater  than  in  emphysema).  This  area  is  elongated  in  a  vertical 


THE    RONTGEN    RAY    IN    MEDICAL    DIAGNOSIS     425 

direction,  as  a  rule,  and  occupies  the  lower  lateral  portion  of  the 
chest.  Toward  the  median  line  may  usually  be  seen  the  thickened 
pleura  and  the  diseased  lung.  The  heart  is  commonly  displaced  to 
the  opposite  side  (Plate  XX,  B). 

Hydro pneumothorax  is  more  common,  and  forms  one  of  the  most 
interesting  fluoroscopic  pictures  that  can  he  found.  In  addition  to 
the  findings  of  pneumothorax,  the  fluid  at  the  base  of  the  pleural 
cavity  may  be  seen  to  move  with  each  respiration  or  each  movement 
of  the  body.  If  the  patient  is  shaken,  the  fluid  is  seen  to  splash 
(Plate  XX,  B). 

Hemothorax. — I  have  examined  two  cases  of  this  character.  Both 
showed  a  more  dense  shadow  than  would  be  produced  by  any  other 
form  of  pleural  effusion  (Plate  XXI,  A). 

Consolidation  and  Pleural  Effusion  Combined. — Plate  XX,  A, 
shows  a  case  of  this  character.  The  shadow  of  the  pleural  effusion  may 
be  seen  to  extend  to  the  fifth  rib  on  the  right  side,  and  to  the  seventh 
rib  on  the  left  side.  The  consolidation  of  the  right  middle  lobe 
shows  through  the  effusion,  and  is  distinctly  more  dense.  Probably 
no  condition  will  give  more  difficulty  in  recognition  than  consolidation 
surrounded  by  an  extensive  pleural  effusion.  In  this  particular  case 
we  had  that  peculiar  physical  sign,  viz.,  tubular  breathing  and  bron- 
chophony  extending  throughout  the  area  of  pleural  effusion.  By 
making  Rontgen  examinations  in  all  such  cases,  we  may  find  that 
consolidation  is  present,  and  that  it  is  the  cause  of  the  peculiar  sign. 
This  sign  is  probably  due  to  the  transmission  of  the  larger  sound- 
waves from  the  bronchi,  through  the  consolidated  lung  to  the  fluid 
in  the  pleural  cavity,  and  thence  through  the  chest  wall  to  the  ear. 
The  striking  of  two  stones  together  under  water  will  convince  most 
people  that  fluids  will  transmit  sound,  but  these  sounds  must  be  of 
the  louder  and  coarser  variety;  therefore,  vesicular  breathing  is  not 
transmitted  through  an  effusion. 

Subphrenic  Abscess. — The  difficulty  in  recognizing  many  of  these 
cases  is  appreciated  by  all  who  have  had  much  experience,  and  there- 
fore any  aid  will  also  be  appreciated.  In  a  case  examined  about 
two  years  ago,  by  means  of  the  screen  I  was  able  to  see  a  decided 
displacement  of  the  diaphragm  upward  as  far  as  the  ninth  rib,  and 
absolute  immobility  on  the  right  side.  The  left  side  of  the  diaphragm 
was  seen  to  move  2^  in.  (12.5  cm.).  The  Rontgen  examination  will 
also  eliminate  some  of  the  diagnoses  with  which  it  may  be  con- 
fused, such  as  pneumothorax,  encysted  pleural  effusion,  or  empyema 
(Plate  XXI,  B). 


426  PHYSICAL    DIAGNOSIS 

THE  HEART 

Normal  Size  and  Position. — This  is  given  under  the  description 
of  the  Rontgenogram  of  the  normal  thorax,  to  which  the  reader  is 
again  referred  (Plate  XII,  A).  Unfortunately,  our  technic  has  not 
been  so  far  perfected  as  to  enable  us  to  photograph  the  heart  in  a  part 
of  its  cycle,  which  would  necessitate  an  exposure  of  less  than  a  second. 
A  few  Rontgenograms  of  the  heart  have  been  made  in  a  fraction 
of  a  second  (Plate  XXII,  A),  but  this  has  not  yet  become  a  working 
method,  for  only  by  the  most  perfect  technic  and  powerful  apparatus 
can  this  be  accomplished. 

Cardiac  Hypertrophy. — An  enlargement  of  the  heart  can  be  more 
certainly  and  accurately  recognized  and  recorded  by  means  of  the 
Rontgen  rays  than  by  any  other  method.  Xot  only  the  general  en- 
largement, but  an  enlargement  of  any  of  the  four  cavities  can  be 
shown  in  the  Rontgenogram.  In  cardiac  hypertrophy  the  enlarge- 
ment is  most  likely  to  involve  either  the  right  or  the  left  ventricle, 
or  both  (Plates  XXII,  B,  and  XXIII,  A). 

Cardiac  Dilation. — The  Rontgenogram  of  cardiac  dilation  differs 
from  the  appearances  of  cardiac  hypertrophy  in  that  the  enlargement 
extends  not  only  laterally,  but  also  in  the  vertical  direction,  showing 
enlargement  of  the  auricles,  and  the  whole  cardiac  shadow  being  more 
globular  (Plate  XXIII,  B).  The  fluoroscope,  in  this  condition,  shows 
beautifully  the  waves  of  contraction. 

Cardiac  Displacement. — The  heart  may  be  displaced  by  a  number 
of  conditions,  each  of  which  can  be  determined  by  means  of  the  Ront- 
gen ray.  Dextrocardia  may  be  due  to  pneumothorax,  as  is  shown  in 
Plate  XX,  B,  or  by  fibrous  bands  occurring  in  the  course  of  tubercu- 
losis, as  is  shown  in  Plates  XXIV  and  XXV,  A.  (See  also  Plate 
XXV,  B.) 

Pericardial  Effusion. — The  shadow  of  pericardial  effusion  differs 
only  slightly  from  that  observed  in  cardiac  dilation,  but  it  is  more 
triangular;  the  apex  of  the  triangle  is  more  acute,  and  by  Rontgen- 
oscopic  examination  the  waves  of  pulsation  are  much  less  distinct. 

Aneurism. — While  the  Rontgen  examination  should  not  be  the 
only  method,  surely  no  other  is  more  reliable  in  making  a  diagnosis. 
The  shadow  will  vary  with  the  size,  form,  and  location  of  the  aneu- 
rism, but  certain  characteristics  will  remain.  The  tumor  mass  will 
involve  the  line  of  the  aorta,  or  the  great  vessels.  It  will  give  a  more 
uniform  shadow,  instead  of  the  localized  areas  which  characterize 
groups  of  enlarged  mediastinal  glands.  By  means  of  the  fluoroscope, 


THE    RONTGEN    EAY    IN    MEDICAL    DIAGNOSIS     427 

the  shadow  will  usually  show  expansile  pulsation.  If,  however,  the 
aneurism  has  thick  or  inelastic  walls,  such  as  occurs  in  a  healed 
aneurism,  this  symptom  will  be  absent.  By  means  of  the  fluoroscope, 
the  aneurism  should  be  examined  from  various  directions,  so  that 
if  any  pulsation  be  present  it  will  not  be  overlooked  (Plate  XXVI, 
A  and  B). 

Mediastinal  Tumors. — The  symptoms  will  almost  always  lead  us 
to  suspect  some  pressure  in  the  mediastinum;  but  since  these  symp- 
toms may  be  due  to  a  number  of  conditions,  the  diagnosis  is  often 
difficult,  and  the  Rontgen  examination  will  be  found  most  valuable. 


RONTGEN    EXAMINATION    OF  THE    GASTRO- 
INTESTINAL   TRACT 

THE  STOMACH 

Occasionally,  in  thin  people,  the  stomach  may  be  seen  naturally, 
because  it  is  distended  with  gas.  As  a  rule,  however,  artificial  assist- 
ance must  be  supplied.  One  method  is  to  distend  the  stomach  with 
gas,  which  is  best  done  by  means  of  an  atomizer  bulb  or  household 
syringe  attached  to  a  stomach  tube.  This  is  sometimes  advisable 
when  a  tumor  of  the  adjacent  viscera  is  under  consideration,  because 
the  lighter  area  due  to  the  gas  may  be  distinguished  from  the  shadow 
of  the  tumor.  Such  examinations,  however,  are  only  possible  under 
favorable  circumstances — e.  g.,  when  the  tumor  is  of  considerable  size 
and  the  patient  thin.  Generally,  inflation  of  the  stomach  with  gas 
is  bad  practise,  and  unsatisfactory. 

A  far  better  method  is  to  render  the  stomach  opaque  by  means 
of  an  emulsion  of  bismuth  subnitrate — about  one  ounce  to  the  pint 
of  milk.  This  method  has  been  used  successfully  by  Williams,  Can- 
non, Rieder,  and  by  myself.  By  this  means  the  size,  form,  position, 
and  the  motility  of  the  stomach  may  be  determined.  In  these  exam- 
inations, the  plate  will  be  found  much  more  useful  than  the  screen 
because  of  the  more  delicate  shadows  obtained,  and  because  it  will 
form  a  permanent  record. 

THE  INTESTINES 

The  examination  of  the  intestines  is  really  only  a  continuation 
of  the  examination  of  the  stomach,  providing  plates  14  X  17  in.  are 
used.  Where  no  interest  is  attached  to  the  study  of  the  stomach  the 


428  PHYSICAL    DIAGNOSIS 

plates  need  not  be  made  until  twelve  hours  after  the  ingestion  of 
the  food,  unless  an  obstruction  in  the  small  intestines  is  suspected. 
Then  the  examination  should  be  made  in  at  least  six  hours.  By  this 
means  the  rate  of  movement  and  the  position  of  the  large  bowel  can 
be  determined.  The  position  of  the  large  bowel,  and  particularly 
the  transverse  colon,  can  be  determined  by  giving  the  emulsion  of 
bismuth  by  enema. 

THE  LIVER 

In  children,  the  outline  of  the  liver,  both  its  upper  and  lower 
border,  can  be  determined,  but  in  adults  the  lower  border  is  usually 
indistinct.  The  upper  border  in  adults  can  usually  be  studied,  except 
where  the  shadow  of  the  heart  interferes.  The  affections  involving 
the  upper  border  of  the  liver  will  be  shown  in  the  changes  in  the 
curve  and  position  of  the  diaphragm.  These  affections  may  be  ab- 
scess, subphrenic  abscess,  gummata,  neoplasms,  echinococcus  cysts,  etc. 

Gall-stones  have  been  recognized  in  a  few  instances,  but  the  Ront- 
gen  examination  is  not  yet  reliable  as  a  diagnostic  factor,  except  as 
possibly  confirmatory  evidence. 

THE  SPLEEN 

The  Rontgen  rays  give  little  assistance  in  the  study  of  this  organ. 
In  children  it  may  be  observed,  and  in  adults  the  lower  border  can 
be  seen  if  the  spleen  is  large,  or  if  the  intestines  are  distended  with  gas. 

THE  KIDNEYS 

Examination  of  the  kidneys  directly  will  give  little  additional  in- 
formation. The  outline  of  the  kidney  can  only  be  seen  in  children, 
in  thin  adults,  or  when  the  kidney  is  much  enlarged. 

Floating  kidney  can  very  rarely  be  observed,  and  then  ordinary 
methods  of  physical  examination  will  determine  the  condition  more 
accurately  and  more  certainly. 

In  general,  the  diagnostic  value  of  the  evidence  obtained  through 
the  Rontgen  ray  will  depend  very  much  upon  the  skill  and  experience 
of  the  operator  both  in  Rontgen  work  and  in  general  medicine.  The 
ability  to  read  a  negative  will  also  depend  in  great  part  upon  the 
physician's  knowledge  of  general  medicine. 


PART  IV 


PLATE    XII 


A. — NORMAL  THORAX  OF  A  YOUNG  MAX.  (1)  SHADOW  OF  THE  HEART.  (2)  SHAD- 
OWS OF  THE  LARGE  PULMONARY  VESSELS.  (3)  THREE  LINES  OF  SHADOW  OF 
THE  DIAPHRAGM.  EXPOSURE,  FIFTEEN  SECONDS. 


B. — INCIPIENT  TUBERCULOSIS,  SHOWING  THE  EARLIEST  POSSIBLE  LESIONS.  (A) 
AREAS  OF  CONGESTION,  AS  DETERMINED  BY  AUTOPSY.  (B)  ISOLATED  TU- 
BERCLES, THE  SIZE  OF  A  PlNHEAD.  (C)  BRANCHING  PULMONARY  VESSEL. 


PLATE    XIII 


A.— SHOWS  INFILTRATION  OF  BOTH  APICES  WITH  SCATTERED  DEPOSITS  LOWER  DOWN, 
AND  DENSE  SHADOWS  PROBABLY  INDICATING  CALCIFIED  TUBERCLES  (A) 
ALSO  A  UNIFORM  SHADOW  AT  THE  ANGLE  OF  THE  RIGHT  SCAPULA  AVHICH 
PROBABLY  INDICATES  A  THICKENED  PLEURA. 


B.- 


-SHOWS  SMALL,  RATHER  DENSE  FIBROUS  BANDS  AT  THE  APICES  OF  BOTH  LUNGS 
— OLD  FIBROUS  OR  HEALED  LESIONS.  (AA)  OLD  CALCIFIED  TUBERCLES.  (B) 
OLD  FRACTURE  OF  NINTH  RIB.  (D)  A  LARGE  DEPOSIT  AT  THE  LEFT  APEX. 


PLATE    XIV 


A. — GENERAL  INFILTRATION   (ACUTE   PROCESS)  OF   BOTH   LUNGS   WITH   No   LARGE 
AREAS  OF  CONSOLIDATION  OR  CAVITATION. 


B. — GENERAL  INFILTRATION,  WITH  A  LARGER  AREA  OF  CONSOLIDATION  TO  THE  LEFT 

OF  THE  APEX  OF  THE  HEART  (A). 


PLATE    XY 


A. — A  LARGE  AREA  OF  COMPLETE  CONSOLIDATION  LYING  TO  THE  LEFT  OF  THE  HEART 
WITH  SMALL  INFILTRATION  PROJECTING  TOWARD  THE  APEX.  THIS  FOL- 
LOWED AN  ABORTION  AND  WAS  AT  FIRST  THOUGHT  TO  BE  AN  INFARCT. 


B. — A  NINE-YEAR-OLD  CHILD.  POSTERIOR  VIEW.  CONSOLIDATION  OF  THE  LOWER 
PORTION  OF  THE  UPPER  LOBE  OF  THE  LEFT  LUNG,  WITH  COMPENSATORY  EM- 
PHYSEMA OF  THE  LOWER  LOBE. 


PLATE    XVI 


A. — (A)  CONSOLIDATION  OF  THE  LEFT  LUNG  OF  MARKED  BUT  NOT  UNIFORM  DEN- 
SITY. THE  OUTLINE  OF  THE  HEART  Is  INDICATED  BY  THE  DOTTED  LINE. 
(fi)  SCATTERED  TUBERCULOUS  DEPOSITS  IN  THE  RIGHT  LUNG. 


B. — GENERAL  INFILTRATION  OF  BOTH  LUNGS,  WITH  AT  LEAST  Two  CAVITIES  IN  THE 
RIGHT  LUNG  AND  ONE  IN  •JHE  LEFT  (C,  C,  C). 


PLATE    XVII 


A- — (A)  CONSOLIDATION  AT  THE  RIGHT  AI>EX.     (B)  SCATTERED  TUBERCULOUS  DE- 
POSITS  IN   THE    BASE   OF   THE    LEFT   LUNG.       (C)    LARGE   CAVITY   IN   THE   LEFT 

APEX,  SUBDIVIDED  BY  FIBROUS  BANDS.  (D,  D)  PROBABLE  OLD  FRACTURES  OF 
THE  RIBS  -WITH  THICKENED  PLEURA  LYING  BENEATH.  (E)  DILATION  OF  THE 
ASCENDING  AORTA.  (F)  COMPENSATORY  EMPHYSEMA  OF  THE  RIGHT  LUNG. 


B- — COMPLETE  CONSOLIDATION  WITH  ABSCESS  FORMATION  AT  THE  LOWER  PORTION 
OF  THE  RIGHT  LUNG  (A) ;  TUBERCULOUS  INFILTRATION  OF  THE  LEFT  LUNG. 


PLATE    XVIII 


A. — (A)  ABSCESS  OF  THE  LEFT  LUNG,  SURROUNDED  BY  TUBERCULOUS  CONSOLIDA- 
TION. (5)  CONSOLIDATION  AT  THE  RIGHT  APEX,  WITH  (C)  COMPENSATORY 
EMPHYSEMA  BELOW. 


B. — GANGRENE  OF  THE  LUNG  (DOTTED  LINE).     DOUBLE  SHADOWS  DUE  TO  COUGH- 
ING WHILE  UNDER  EXAMINATION. 


PLATE    XIX 


A. — SAME   CASE    AS    PLATE    XVIII,    B,    AFTER   OPERATION.     ABSEXCE  OF  PORTION 
OF  RESECTED  FIFTH  RIB  SHOWN;  ALSO  OF  THE  SHADOWS  AT  THE  RIGHT  APEX. 


B. — GENERAL  SMALL  AND  PROBABLY  EARLY  INFILTRATION,  WITH  A  THICKENED 
PLEURA  (a)  AND  A  CALCIFIED  TUBERCLE  NEAR  THE  ANGLE  OF  THE  RIGHT 
SCAPULA  (6). 


PLATE    XX 
'  -q 


A. — PLEURAL  EFFUSION  EXTENDING  TO  THE   FIFTH  RIB  POSTERIORLY  ON  THE  RIGHT 

SIDE  AND  TO  THE  SEVENTH  RlB  ON  THE   LEFT  SlDE ;  ALSO  A  CONSOLIDATION  ON 

THE  RIGHT  SIDE  IN  THE  REGION  OF  THE  RIGHT  MIDDLE  LOBE,     (e)  COMPENSA- 
TORY EMPHYSEMA  ABOVE  THE  EFFUSION. 


-LIGHT  AREA  ox  THE  LEFT  SIDE  DUE  TO  PNEUMOTHORAX.  SHADOW  OF  FLUID 
AT  THE  BOTTOM,  ABOUT  Two  INCHES  ABOVE  THE  DIAPHRAGM.  COMPRESSION 
OF  THE  LEFT  LUNG  WITH  CAVITIES  AT  THE  APEX  (C,  C,  C).  HEART  AND  AORTA 
IN  THE  RIGHT  CHEST.  TUBERCULOUS  DEPOSITS  IN  THE  RIGHT  LUNG  WITH 
CAVITY  AT  THE  APEX  (C). 


PLATE    XXI 


A. — HEMOTHORAX  ox  THE  LEFT  SIDE  OF  THE  CHEST,   DISPLACING  THE  HEART  TO 

THE  RIGHT. 


. 


. SUBPHRENIC    ABSCESS    OF    THE    RlGHT    SlDE.        DIAPHRAGM     DISPLACED    UPWARD 

OXE    AXD    OXE-HALF    IXCHES. 


PLATE    XXII 


- — A  NINE-YEAR-OLD  CHILD.      ANTERIOR  VIEW.      CONSOLIDATION  OF  THE  LOWER 
PORTION  OF  THE  LEFT  UPPER  LOBE. 


MARKED  HYPERTROPHY  AND  DILATION  OF  THE  LEFT  VENTRICLE.  CONGESTION 
OF  THE  BASE  OF  THE  RlGHT  LUNG.  SOME  ENLARGEMENT  OF  THE  WHOLE 
HEART. 


PLATE    XXIII 


A. — (A)  HYPERTROPHY  OF  THE  RIGHT  VENTRICLE.  (B)  HYPERTROPHY  OF  THE  LEFT 
AURICLE.  (C)  LEFT  VENTRICLE,  NEARLY  NORMAL  ix  SIZE.  (D,  D)  PROBABLE 
TUBERCULOUS  DEPOSITS. 


B. — MARKED  CARDIAC  DILATION.  NOTE  THE  GLOBULAR  APPEARANCE  OF  THE  HEART, 
AND  THE  ENLARGEMENT  UPWARD  OF  THE  LEFT  AURICLE.  THE  DOTTED  LINES 
INDICATE  THE  ARCH  OF  THE  AORTA,  AND  THE  DIAPHRAGM,  ALSO. 


PLATE    XXIV 


DEXTROCARDIA  DUE  TO  TUBERCULOSIS.  COMPLETE  CONSOLIDATION  OF  THE  RIGHT 
LUNG,  WITH  FIVE  CAVITIES  AT  THE  APEX  (LIGHT  AREAS  SURROUNDED  BY 
DENSE  SHADOWS).  COMPENSATORY  EMPHYSEMA  OF  LEFT  LUNG.  TUBER- 
CULOUS INFILTRATION  AT  LEFT  APEX. 


PLATE    XXV 


j 

A. — DEXTROCARDIA.  TUBERCULOUS  DEPOSITS  IN  THE  LEFT  APEX,  WITH  COMPEN- 
SATORY EMPHYSEMA  BELOW.  COMPLETE  CONSOLIDATION  OF  RIGHT  LUNG, 
WITH  A  CAVITY  AT  THE  APEX,  AND  ANOTHER  AT  THE  BASE  (c,  c). 


B. — SHOWS:  (1)  THE  LEFT  SIDE  OF  THE  DIAPHRAGM  FOUR  INCHES  HIGHER  THAN  THE 
RIGHT.  (2)  THE  HEART  DISPLACED  TO  THE  RIGHT.  (3)  THE  OUTLINE  OF 
THE  STOMACH,  BELOW  THE  DIAPHRAGM,  CONTAINING  A  BOLUS  OF  FOOD.  (4) 
THE  DESCENDING  COLON,  SHOWING  THE  TRANSVERSE  FOLDS.  (5)  SHADOWS 
OF  CONGESTION  OF  THE  LUNGS. 


PLATE    XXVI 


A. — ANEURISM  OF  THE  ARCH  OF  THE  AORTA,  INVOLVING  CHIEFLY  THE  DESCENDING 
PORTION.     THE  HEART  Is  DISPLACED  DOWNWARD  AND  TO  THE  LEFT. 


A 


B. — (A)  ANEURISM  OF  THE  DESCENDING  AORTA.  SOME  EROSION  OF  THE  THIRD, 
FOURTH,  AND  FIFTH  DORSAL  VERTEBRAE  Is  SHOWN.  (5)  ENORMOUS  EN- 
LARGEMENT OF  THE  LEFT  VENTRICLE.  (C)  A  SECOND  ANEURISM,  OR  AN  EN- 
LARGED RIGHT  VENTRICLE.  (D)  COMPENSATORY  EMPHYSEMA  OF  THE  RIGHT 
LUNG. 


PLATE    XXVII 


TORTUOSITY  OF  THE  ARCH  OF  THE  AORTA  INDICATED  (A)  BY  THE  AORTIC  SHADOW 
BEING  PROJECTED  ALMOST  DIRECTLY  OUTWARD  ON  A  LEVEL  WITH  THE  INTER- 
SPACE. (B)  HYPERTROPHIED  LEFT  VENTRICLE. 


PLATE    XXVIII 


GASTROPTOSIS.  (1)  ONE-CENT  PIECE  ON  THE  UMBILICUS.  (2)  THE  STOMACH  OCCU- 
PYING THE  VERTICAL  POSITION,  AND  THE  PYLORUS  DISPLACED  DOWNWARD 
FOUR  INCHES.  (3)  THE  RIGHT  SACRO-ILIAC  SYNCHONDROSIS.  (4)  THE 
CECUM,  EMPTY.  (5)  DESCENDING  COLON,  ALSO  EMPTY.  (6  and  7)  HEADS  OF 
THE  FEMORA. 


PLATE    XXIX 


GASTROPTOSIS.  (1)  A  CENT  ON  THE  UMBILICUS.  (2)  THE  STOMACH,  HAVING  MOVED 
INTO  THE  PELVIS.  (3)  RIGHT  SACRO-ILIAC  SYNCHONDROSIS.  (4  and  5)  CECTJM 
AND  DESCENDING  COLON,  RESPECTIVELY. 


PLATE    XXX 


CASE  OF  GASTROTOPSIS.  (1)  ONE-CENT  PIECE  ON  THE  NAVEL.  (2)  STOMACH.  (3) 
RIGHT  SACRO-ILIAC  SYNCHONDROSIS.  (4  and  5)  EMPTY  CECTJM  AND  DESCEND- 
ING COLON,  RESPECTIVELY.  (8)  TRANSVERSE  COLON,  EMPTY.  (9)  SHADOWS 
OF  FOOD  IN  THE  SMALL  INTESTINE. 


PLATE    XXXI 


(1)  ONE-CENT  PIECE  ON  THE  NAVEL.  (2)  TRANSVERSE  COLON.  (3)  RIGHT  SACRO- 
ILIAC  SYNCHONDROSIS.  (4)  CECUM  AND  ASCENDING  COLON,  SHOWING  THE  FOOD 
AFTER  TWENTY-FOUR  HOURS.  (5)  ISOLATED  MASSES  OF  FOOD  IN  THE  SMALL 
INTESTINES.  (6)  DESCENDING  COLON,  EMPTY. 


PLATE    XXXII 


(1)  ONE-CENT  PIECE  ON  THE  UMBILICUS.     (2)  CECUM  AND  ASCENDING  COLON.     (3) 
TRANSVERSE  COLON,  EMPTY.     (6)  RIGHT  SACRO-ILIAC  SYNCHONDROSIS. 


INDEX 


31 


INDEX 


Abdomen,  abscess  of,  372,  375. 
anatomic  landmarks  of,  363,  366. 
auscultation  of,  379. 
contour  of  normal,  367. 
depressions  of,  local,  370. 
distention  of,  fluid,  373. 

solid  general,  374. 
division  of,  into  quadrants,  364. 

into  sextants,  365. 
enlargement  of,   from  accumulation 

of  gas,  373. 

from  dietetic  causes,  373. 
from  excess  of  fat,  372. 
from  organic  and  neoplastic  causes, 

374 

local,  370. 

uniform  and  symmetrical,  367. 
examination  of,  363,  366. 
fatty  growths  in,  375. 
free  fluid  in,  379. 
nine  regions  of,  363. 
palpation  of,  position  of  patient  for, 

370. 

preparation  of  hands  for,  371. 
pathologic    signs    on    inspection   of, 

367. 

pendulous,  in  women,  367. 
relaxation  of,  371,  372. 
retraction  of,  369,  374. 
size  and  shape  of,  367. 
zones  and  regions  of,  363. 
Abdominal     movements,     circulatory, 

369. 

peristaltic,  369. 
respiratory,  369. 
vascular,  369. 

vermicular,  after  excitation,  369. 
Abdominal   muscle,   local   contraction 

of,  372. 
Abdominal  walls,  color  of  the  skin  of, 

368. 

rigidity  of,  371,  372. 
Abscess,  appendiceal,  389,  390. 
of  liver,  393. 
of  lung,  164. 
pelvic,  376. 

pericecal  or  periappendiceal,  376. 
perinephric,  376,  377,  409. 
perisigmoidal,  377. 


Abscess,  psoas,  376,  377. 

subdiaphragmatic,     or     subphrenic, 

376,  425. 

Acoustic  law,  146. 
"Acromial  angle,"  20. 
Actinomycosis  of  lung,  120. 
Adhesions,  pericardial,  240. 

pleuritic,  230,  339. 

Adipose   tissue,    influence  of,   on   per- 
cussion, 100. 
Age,  effect  of,  upon  percussion,  102. 

upon  position  of  heart,  220. 
Aged,  borders  of  lungs  in,  107. 
"Ague-cake,"  407. 
Air,  complementary,  40. 

reserve  or  supplemental,  40. 
tidal  movement  of,  41,  162. 
tidal  or  breathing,  41. 
Air-containing  structures,  sensation  of 

resistance  in,  97. 
sounds  of,  97. 
Air  currents,   obstruction  to  the  exit 

of,  158. 

Airless  structures,  sensation  of  resist- 
ance in,  97. 
sounds  of,  97. 

Air-passages,  large,  stenosis  of,  330. 
Air-vesicles,  compression  of,  162. 
consolidation  of,  109. 
exudation  within,  162. 
Alcoholism,  284. 
Alveolar  walls,  distention  of,  212. 

weakened  elasticity  of,  212. 
Anatomic  inference,  246. 
Anatomy,  topographical  and  relational, 

6,  7. 
Anemia,  272,  274,  319. 

accompanied  by  murmurs,  338. 
heart  sounds  in,  269. 
venous  hum  of,  347. 
Aneurism,  aortic,  19,  273,  377. 
differentiation  of,  375. 
rupture  of,  56. 
symptom  of,  313. 

as  cause  of  bronchial  breathing,  163. 
denoted  by  increased  precordial  dul- 

ness,  257. 
diagnosis  of,  426. 
by  palpation,  315. 

433 


434 


INDEX 


Aneurism,    epigastric    and    umbilical, 

377. 

healed,  427. 

of  ventricular  wall,  225. 
Aneurismal  sac,  338. 
Angina   pectoris,    increased   pulse-rate 

in,  320. 
Angle,  epigastric,  16,  30,  210. 

of  Louis,  14,  16,  21,  24,  27,  30,  210. 
subcostal,  30. 
Angulus  Ludovici,  14. 
Antiperistalsis,  383. 
Aorta,  abdominal,    aneurism    of,    227, 

315. 

pulsation  of,  315,  377. 
topographic  anatomy  of,  366. 
arch  of,   aneurism  of,    19,   56,   223, 

230,  336. 
position  of,  218. 
visible  pulsation  of,  313. 
atheroma  of,  273,  307. 
dilation  of,  19,  289,  359. 
fatty  and  relaxed,  359. 
movable  from  side  to  side,  337. 
palpation  of,  315. 
position  of,  217. 
recoil  pressure  within,  273. 
stenosis  of,  241. 
tortuosity  of,  337. 
Aortic  cusps,  leakage  at,  358. 
'Aortic  insufficiency,  254,  272,  274,  292, 

314,  324. 

Aortic  regurgitation,  338,  339. 
differentiation  of,  356. 
murmurs  associated  with,  359. 
palpation  in  a  case  of,  357. 
physical  pathology  of,  358. 
physical  signs  of,  on  inspection,  357. 
Aortic  sound,  booming  quality  of,  273. 
changed  intensity  of,  273,  274. 
weakening  of,  274. 
Aortic  stenosis,  274,  297,  324,  338. 
differentiated    from    mitral    regurgi- 
tation, 352. 
Aortic    thrills,   diastolic   and    systolic, 

243. 

Aortic  valve,  219. 
Apex-beat,  221. 
absence  of,  233. 
diffuse,  238. 
diminution  of,  233. 
diseases  in  which  occurs  increased, 

240. 
displacement    of,    downward,     229, 

230. 
pathologic  and  physical  causes  of, 

229. 

to  left  and  right,  230. 
upward,  229. 
doubling  of,  241. 
effect  of  stimulants  upon,  239. 
extent  of,  232,  238. 


Apex-beat,  force  of,  238,  239. 

imperceptibility  of,  to  touch,  240. 

in  childhood  and  old  age,  239. 

inspection  of,  228. 

position  of,  238. 

affected  by  distention  of  stomach, 

229. 

by  posture,  229. 
by  pregnancy,  229. 
by  respiratory  movement,  229. 
method  of  ascertaining,  238. 
normal  variations  in,  228. 

rhythm  of,  241. 

weakening  or  lessening  of,  240. 
Apex  of  lung,  as  seat  of  incipient  tu- 
berculosis, 98. 

resonance  of,  104. 

tuberculous  consolidation  of,  154. 

tuberculous  infiltration  of,  158. 
Aphonia,  tussive  fremitus  in,  71. 
Apical  first  sound,  weakening  of,  272. 
Apical   impulse,   abnormal   extent   of, 
231. 

displacement  of,  351. 

heaving  character  of,  232. 
Apical  vesicles,  collapse  of,  105. 
Appendicitis,  chronic,  376. 
Appendix,  inflammation  of,  377. 

region  of,  enlargement  in,  376. 

thickening  and  swelling  of,  389.  390. 
Appendix  vermiformis,  location  of,  388. 
Arrhythmia,  322. 

cardiac,  234. 

causes  of,  277. 
Arteria  plena,  319. 
Arteria  vacua,  319. 
Arterial  hypertension,  chronic,  273. 
Arterial  murmurs,  337,  338. 
Arterial  sounds,  337,  338. 
Arterial   walls,   conditions   of,   normal 
and  abnormal,  318. 

disease  of,  338. 

examination  of,  317. 
Arteries,  conduction  sounds  in,  338. 

inspection  of,  313. 

position  of,  217,  218. 

volume  of,  319. 
Arterioles,  resistance  in,  319. 
Arteriosclerosis,  314,  318. 
Artery,  beaded,  318. 

calcification  of,  318. 

carotid,  palpation  of,  260. 

innominate,  bifurcation  of,  20. 

pipe-stem,  319. 

subclavian,  19. 

wiry  and  contracted,  318. 
Ascaris  lumbricoides,  397. 
Ascites,  351. 

causes  of,  374,  379. 

displacing  apex-beat,  229. 

liquid  fluctuation  of,  373. 

significance  of,  397. 


J  N  DEX 


435 


Asthma,  breath-sounds  in,  158. 

bronchial,  349. 

differentiated  from  cardiac,  350. 

jugular  undulations  in,  341. 
Asthmatic  breathing,  60. 
Asymmetries  of  movement  perceptible 

on  palpation,  64. 

Atelectasis,  as  cause  of  impaired  reso- 
nance, no. 

bronchovesicular  breathing  in,  160. 

crepitant  rales  in,  178. 

physical  signs  in,  197. 
Atheromatous  degeneration,  337. 
Athletes,  change  of  heart  sounds  in, 
271. 

respiratory  expansion  in,  36. 

vesicular  resonance  in,  88. 
Athleticism,  284. 
Atrophy  of  heart,  272. 
Auricles,  enlargement  of,  255,  426. 
Auricular  systole,  309,  343. 
Auscultation,  132. 

as  a  method  of  physical  examination, 
133. 

direct,  141. 

history  of,  132. 

immediate,  259. 
advantages  of,  133. 

in  hypostasis,  207. 

Laennec's  classic  work  on,  132. 

mediate,  133. 

objects  of,  144. 

of  the  heart,  259. 

phenomena  of,  144. 

position  of  patient  for,  141. 

stethoscopic,  134. 

systematic  and  comparative,  142. 

technic  of,  133,  141. 
Auscultatory  percussion,  246,  399. 
Auscultatory  phenomena,  168. 
Axillary  artery,  murmurs  in,  339. 
Axillary  lines,  anterior  and  posterior, 

18. 
Axillary  regions,  percussion  of,  101. 

Baccelli's  sign,  193. 
Bacillus,  gas-forming,  373. 
"Bag  of  nuts,"  sensation  of,  396. 
Ballotement  phenomenon,  410. 
"Bandbox"  percussion  note,  93,  116. 
Basedow's  disease,  232. 
Bell-tympany,  126. 
Bellows  sound,  296. 
Biermer's  change  of  sound,  126,  127. 
Bile-ducts,  inflammation  of,  396. 
Biliary  cirrhosis,  hypertrophic,  395. 
Bladder,  distended,  377. 
Blood,  circulation  of,  262. 

diseases  of,  causing  splenic  enlarge- 
ment, 404. 

jugular,  velocity  of,  347. 

specific  gravity  and  plasticity  of,  298. 


Blood  pressure,  decrease  of,  339. 
instruments  for  study  of,  325. 
normal  and  pathologic,  327. 
Blood  pressure  quotient,  327. 
Blood  stream,  force  of,  297. 

peripheral  resistance  to,  273. 
Blood-supply,  of  pulse,  317. 

volume  of,  319. 
Blood-vessels,  congenital  hypoplasia  of, 

338. 

examination  of,  313. 
fatty  degeneration  of,  338. 
great,  positions  of,  217. 

shadow  of,  420. 

Body,  objective  investigation  of,  3. 
Bone,  peculiar  resonance  of,  88,  250. 

"wooden"  sound  of,  88. 
Borborygmi,  390. 
Bowel,  distention  of,  by  gas,  373,  389. 

intussusception  of,  376,  377. 
Bowies'  stethoscope,  135,  138,  139. 
Brachycardia,  320. 
Bradycardia,  234. 

essential,  320. 
Breath,  holding  of,  419. 
Breath-sounds,  alterations  in  pitch  of, 

83. 

in  quality  of,  83,  159. 
intensity,  rhythm,  and  quality  of,  152. 
normal  bronchovesicular,  147. 
study  of,  144. 

unilateral  exaggeration  of,  153. 
whiffing,  156,  161. 
Breathers,  poor,  110,  179. 
Breathing,  absent  or  suppressed,  155. 
bronchial,  145,  157,  161. 
causes  of,  162. 
high  pitch  of,  161,  163. 
normal  variations  in,  146. 
quality  and  rhythm  of,  163. 
Skoda's  description  of,  145. 
bronchocavernous,  164. 
bronchovesicular,  145. 

pathologic  source  of,  159. 
cavernous,  causes  of,  164. 

weakening  of,  164. 
Cheyne-Stokes,  60,  333. 
deficiency  of,  unilateral,  bilateral,  or 

intermittent,  155. 
exaggerated,  cause  of,  153. 

from  tight  lacing,  154. 
forced,  31,  36,  51. 
metamorphosing,  167. 
systolic  vesicular,  152. 
transitional,  159. 
tubular,  425. 

types  of,  differentiation  of,  160. 
vesicular,  local  intensification  of,  153. 

pathologic  modifications  of,  153. 
vesiculocavernous,  164. 
wavy  or  jerky,  pathologic,  156. 
weak,  shallow,  or  senile,  154. 


436 


I  X  HEX 


Breathing  volume,  estimation  of,  40. 
Breathlessness,  significance  of,  349. 
Broadbent's  sign,  226,  241. 
Bronchi,  dilation  of,  circumscribed,  120. 
with  thickening  of  walls,  110,  191. 
main,  bifurcation  of,  23. 
primary,  27. 
surrounded  by  dense  consolidations, 

192. 

total  occlusion  of,  193. 
Bronchial  asthma,  spasmodic,  349. 
Bronchial  catarrh,  158,  184,  187. 
Bronchial  fremitus,  70. 

differentiated  from  pleural  fremitus, 

71. 

Bronchial  glands,  enlarged  and  tuber- 
culous, 110. 
Bronchial  tubes,  diminished  caliber  of, 

68. 

exudation  within,  110. 
varying  arrangement  of,  99. 
Bronchial  whisper,  189,  191. 
Bronchiectasis,  120. 

bronchial  fremitus  in,  71. 
with  reactive  pneumonia,  183. 
Bronchiolitis,  tuberculous,  155,  311. 
Bronchitis,    ch  onic,    associated    with 

fibroid  phthisis,  190. 
associated  with  senile  emphysema, 

190. 
simple,  analysis  of  physical  signs  in, 

200. 

auscultation  in,  200. 
diagnosis  of,  201. 

exclusion   of  pulmonary   involve- 
ment in,  200. 
inspection  in,  200. 
palpation  and  percussion  in,  200. 
rales  in,  200. 
vocal  resonance  in,  200. 
Bronchophony,  189,  190,  191,  425. 
Bronchopneumonitis,  178. 
in  children,  55. 
in  old  people,  110. 
Bronchus,  dilated,  164. 
left,  greater  length  of,  124. 
nearness  of,  to  chest  wall,  66. 
occlusion  of,  causing  total  absence  of 

fremitus,  69. 

size  or  diameter  of,  27,  66. 
Bruits,  283. 

aneurismal,  285,  380. 
de  diable,  346. 
de  galop,  279. 
de  pot  fete,  127,  129. 
systolic,  380. 

Build,  influence  of,  in  disease,  205. 
Bulging,  aneurismal,  222. 
epigastric,  382. 
of  chest,  expiratory  rise  in,  55. 

inspiratory  fall  in,  55. 
precordial,  222. 


Calculi,  biliary,  396,  397. 

in  the  bowels,  388. 
Calipers,  use  of,  35. 
Cancer,  gastric,  377,  383. 

navel,  396. 

of  liver,  393,  396. 

of  lung,  164. 

of  suprarenals,  376.  • 

parietal,  375. 

scirrhous,  of  pylorus,  383. 
Capillaries,  filling  and  emptying  of,  339. 
Capillary  pulse,  339,  357. 
Caput  Medusae,  368. 
Carcinoma  of  sigmoid  flexure,  377. 

of  stomach,  384. 
Cardia,  stenosis  of,  387. 
Cardiac  cycle,  262. 

Cardiac    disease,    "broken    compensa- 
tion" in,  62. 
Cardiac  dulness,  absence  of,  253,  257. 

absolute,  218,  245. 

altered  by  change  of  position,  256. 

apparent  increase  of,  256. 

area,  limits,  and  shape  of,  249,  253. 

circumscribed,  255. 

clinical  value  of,  247. 

covered,  245,  247. 

deep,  245,  247. 

diminished,  253,  257. 

displaced,  253,  257. 

entire,  245. 

exposed,  245,  246. 

extending  upward  and  laterally,  255. 

increased,  253,  255. 

relative,  245,  247. 

superficial,  218,  245,246. 

total  area  of,  249. 

vertical  and  transverse,  250. 
Cardiac  impulse,  abnormal  strength  of, 
234. 

absence  of,  234. 

diffuse,  flabby,  351. 
Cardiac  irregularity,  235. 
Cardiac  murmurs,  282. 
Cardiac  power,  variations  in,  319. 
Cardiac  sounds,  intermittency  of,  281 

irregularity  of,  281. 

loudness  of,  267. 
Cardiac  weakness,  111,  233,  279,  336. 

caused  by  general  exhaustion,  270. 
Cardiographic  tracings,  244. 
Carotid  impulse,  transmitted,  345. 
Catarrh,  bronchial,  158. 

associated  with  pleurisy,  184. 
rales  indicative  of,  187. 

gastro-intestinal,  390. 

obstructive  duodenal,  397. 
"Catch"  in  the  side,  60. 
Caverns.     See  Pulmonary  Cavities. 
Cavities,  air-containing,  volume  of,  93 

bronchiectatic,  126. 

revealed  by  ringing  rales,  176. 


INDEX 


437 


Cavities,  closed,  tension  of  walls  of,  94. 

volume  of,  94. 
cylindrical,  length  of,  94. 

pitch  of,  94. 
pulmonary,    as    cause    of   amphoric 

respiration,  166. 

heart  sounds  accompanying,  270. 
resonant  rales  in,  176. 
surrounded  by  solidified  tissue,  191. 
thick-walled  bronchiectatic,  111. 
tuberculous,  125. 

tympanitic  note  over,  90. 
Cecum,  cancer  of,  376. 

chronic  thickening  of,  390. 
malignant  disease  of,  389. 
seat  of,  388. 
Cerebrospinal  meningitis,  complicated 

by  endocarditis,  313. 
Cervical  veins,  engorgement  of,  341. 

swelling  of,  341. 
Chemistry,  clinical,  6. 
Chest  (thorax),  11. 

abnormal  shape  of,  42,  48. 
caused  by  occupation,  30. 
unilateral,  48. 
alar  or  pterygoid,  42. 
anatomical  landmarks  of,  14. 
anatomy  of,  topographical  and  rela- 
tional, 13. 

anterior  aspect  of,  18. 
average  circumference  of,  35. 
barrel-shaped,  45. 
bulging  of,    local   or   circumscribed, 

50. 

unilateral,  4. 

comparative  observation  of,  29. 
contraction  of,  disease  the  cause  of, 

49. 

unilateral,  48. 
deformity  of,  47,  229,  230. 
depressions  of,  local  or  circumscribed, 

50. 

diameters  of,  37. 

diseases  of,  physical  diagnosis  of,  3. 
disproportions  in  size  of,  41. 
elevation  of,  53. 
emphysematous,  44,  53. 
enlargement  of,  artificially  produced, 

49. 

pathologic,  41. 
unilateral,  49. 

expansion  of,  diminished,  52,  53. 
increased,  51. 
respiratory,  56. 
unilateral,  37,  54. 
funnel-shaped,  46. 
inspection  of,  28. 

in  emphysema,  209. 
irregularities  of,  congenital  and  ac- 
quired, 30. 
lateral  aspects  of,  22. 
length  of,  37, 


Chest,  mensuration  of,  34. 

in  emphysema,  210. 
movements  of,  30,  55,  62. 

abnormal  or  diminished,  54. 
normal  appearance  of,  29,  419. 
nutrition  of,  34. 
palpation  of,  63. 
paralytic  or  phthisinoid,  42,  43. 
physical  diagnosis  in  diseases  of,  13. 
physical  signs  in,  13. 
pigeon,  45,  54. 
posterior  aspect  of,  22. 
rachitic,  45. 
regions  of,  axillary,  22. 

clavicular,  19. 

inferior  sternal,  21. 

infra-axillary,  22. 

infraclavicular,  20. 

inframammary,  21. 

infrascapular,  22. 

interscapular,  23. 

mammary,  20. 

scapular,  22. 

superior  sternal,  21. 

supraclavicular,  19. 

suprascapular,  22. 

suprasternal,  18. 
retraction  of,  after  cirrhosis  of  lung, 

48. 

Rontgenography  of,  418. 
Rontgenoscopy  of,  419. 
semicircumference  of,  36. 
shape  of,  31,  41. 
size  of,  31,  36,  41. 

unilateral  abnormality  of,  48. 
smallness  of,  pathologic,  42. 
symmetry  of,  29,  31,  41,  47. 
tapping  of  fluid  from,  15. 
topography  of,  13,  17. 
transverse  constriction  of,  45,  46. 
vesicular  sounds  in,  151. 
Chest  muscles,  tension  of,  144. 
Chest  pantograms,  39. 
Chest  wall,  pathologic  conditions  in,  50. 

tension  of,  93. 
Chests,  broad  and  deep,  comparison  of, 

40. 

Cheyne-Stokes  breathing,  60,  333. 
Children,  borders  of  lungs  in,  107. 
inspiratory  dyspnea  in,  62. 
liver  dulness  in,  398. 
percussion  of,  252. 

while  crying,  84. 
physical  signs  in,  197. 
prominences  of  chest  in,  51. 
respiratory  rhythm  in,  34. 
retraction  of  lower  chest  in,  53. 
type  of  respiration  in,  31. 
vocal  resonance  in,  197. 
Chlorosis,   accompanied   by  murmurs, 

338. 
hypoplasia  of,  314. 


438 


INDEX 


Chondrosternal  junction,  third,  15. 

Circulation,  venous,  340. 

Cirrhosis,  atrophic,  395. 

Clavicles,  immediate  percussion  of,  98. 

location  of,  14. 
Click,  at  apex,  significance  of,  173. 

mucous,  180. 
Coin-clinking  test,  126. 
Coin  percussion,  126,  213. 
Collapse,  arrhythmia  in,  277. 
Collyer's  pelvimeter,  37. 
Colon,  ascending,  cancer  of,  376. 
enlargement  of,  376. 

distention  of,  375,  376,  388,  397. 

inflation  of,  as  a  test,  410,  412. 

malignant  disease  of,  389. 

position  of,  388,  428. 

prolapse  of,  377. 

rate  of  movement  in,  428. 

splenic  flexure  of,  404. 

transverse,  distention  of,  375,  376. 

tumors  of,  377,  389. 
Congestion,  bronchopulmonary,  180. 

pulmonary,  206,  207. 
Coni  arteriosi,  261. 
Consolidation,   pneumonic,   simulation 

of,  198. 

Consumption,  predisposition  to,  179. 
Conus  aortae,  262. 
Conus  arteriosus,  dilation  of,  305. 
Cor  bovinum,  359. 
Cords,  aberrant,  307. 
Corset  liver,  394. 
Corsets,  effect  of,  on  breathing,  32,  154. 

tight,  effect  of,  on  abdomen,  367. 
Costovertebral  articulation,  15. 
Cough,  as  a  physical  sign,  194. 

as  adjuvant  to  auscultation,  195. 

auscultation  of,  194. 

barking,  195. 

sepulchral,  195. 
Cracked-pot  sound,  127,  130. 

moist,  127,  128. 

pathological,  128. 
Crackling,  168,  177,  180. 

pleuritic,  183. 
Crepitans  redux,  178. 
Crepitation,  168,  312,  400. 

artificial,  180. 

atelectatic,  178. 

laryngeal,    as   sign    of   tuberculosis, 
179. 

physiologic,  179,  187. 

pleural,  178,  183. 
Crepitus  of  broken  rib,  187. 

over  gall-bladder,  375. 

peritoneal,  380. 

Crural  artery,  double  sound  and  mur- 
mur of,  338. 

Cutaneous  furrows,  marking  of,  72. 
Cyanosis  as  an  objective  symptom,  4. 
Cyrtometry,  37,  42. 


Cyst  of  broad  ligament,  377. 
of  kidney,  409,  410. 

"Death-rattle,"  169,  172. 
Deformities,    local,  revealed  by  palpa- 
tion, 64. 

of  chest,  48. 

Deglutition  murmur,  387. 
Delirium  cordis,  323. 
Depression,  suprasternal,  18. 
Dermal  hearing,  84. 
Dermatitis  caused  by  Rontgenoscopy, 

418. 

Dextrocardia,  230,  258,  426. 
Diagnosis,  physical,  3. 
Diaphragm,  displacement  of,  425. 

elevation    of,    from    abdominal    en- 
largement, 117. 

excursion  of,  normal,  420. 

flattening  of,  400. 

immobility  of,  425. 

movements  of,  32. 

revealed  by  palpation,  65. 

"peeling  off"  of,  33. 

restriction  of,  51. 

shadow  of,  420.  3^ 

summit  of,  27. 

Diaphragmatic  phenomenon,  32. 
Diarrhea,  colliquative,  274. 
Diastolic  shock,  237,  273. 
Diastolic  silence,  prolongation  of,  277. 
Diastolic  sound,  accentuation  of,  273. 

apparent  or  false  doubling  of,  280. 

duration  and  pitch  of,  261. 

intensity  and  quality  of,  261. 

intensity  of  component  elements  of, 
268. 

reduplication  of,  279. 
Dicrotism,  329. 

Diphtheria,  paralysis  of  heart  in,  279. 
Doeppler's  principle,  122. 
Dropsy,  abdominal,  373. 

of  the  peritoneum,  367. 
Ductus  arteriosus,  permanent  patency 

of,  244. 

Dulness    on    percussion,    diseases    in 
which  revealed,  110. 

intrapulmonary     and     extrapulmo- 
nary,  109. 

normal  tympanitic,  90. 

normal  vesicular,  90. 

slight  and  marked,  109. 
Duroziez's  sign,  359. 
Dyspeptic  conditions,  flatulent,  390. 
Dyspnea  as  a  symptom,  59. 

as  an  objective  symptom,  4. 

diabetic,  60. 

expiratory,  53,  62,  349. 

from  obstruction  by  foreign  body,  61. 

inspiratory,  61. 

mixed  inspiratory  and  expiratory,  62. 

pathologic  and  physiologic,  59. 


INDEX 


439 


Echinococcus   disease,  396.     (See  also 
Table  on  Diagnosis  of  Diseases 
of    the    Liver,    bet.    pp.    396- 
97.) 
Echo,  amphoric,  125,  166. 

metallic,  125. 
Edema,  abdominal,  372. 
pulmonary,  111,  207. 
Effusion,  peritoneal,  377. 

pleuritic,  129.     See  also  Pleural  Ef- 
fusion. 
Egophony,  190. 

as  sign  of  vocal  resonance,  192. 
in  pneumonia,  206. 

Elephantiasis.  (See  Table  on  Diagnosis 
of  Diseases  of  the  Liver,  bet.  pp. 
396-97.) 

Emaciation,  accompanying  tuberculo- 
sis, 125. 

of  chest,  significance  of,  34. 
Embryocardia,  277. 
Emotional    excitement,    effect    of,    on 

apex-beat,  239. 
Emphysema,  183. 

breathing  characteristic  of,  157,  158. 
compensatory,  54,  116,  399. 
conditions  hidden  by,  213. 
differentiated    from    pneumothorax, 

212. 

displacing  apex-beat,  230. 
displacing  heart,  270. 
displacing    liver    dulness,   399,    400 

402. 

encroaching  upon  heart,  257. 
enlargement  of  chest  in,  41. 
hyperresonance  in,  93. 
hypertrophic,  auscultation  in,  211. 
diagnosis  of,  212. 
palpation  and  percussion  in,  211. 
physical  examination  in,  209. 
synthetic    analysis   in   a   case   of, 

212. 

impairment  of  fremitus  in,  68. 
inflation  of  chest  in,  44. 
interlobular,    crumpling   sounds    in, 

187. 

jugular  undulations  in,  341. 
lessened  apical  impulse  in,  240. 
obstruction  of  lungs  from,  271. 
revealed  by  Rontgen  rays,  422. 
senile,  191. 

size  and  shape  of  thorax  in,  209. 
vicarious,  50,  116. 
vocal  resonance  in,  193. 
Empyema,  evacuation  of  pus  of,  128. 

pulsating,  55,  72,  226. 
Endarteritis,  338. 

Endocardial  murmurs,  organic,  303. 
cause  of,  284. 
pitch  and  quality  of,  296. 
Endocarditis,  240. 

as  cause  of  murmurs,  284. 


Enlargement  of  chest  from  occupation, 

41. 
in  asthmatics  and  mountaineers,  41. 

Enlargements,  local,  features  of,  374. 

Enteroclysis,  390. 

Enteroliths,  376,  377,  388. 

Enteroptosis,  377. 

Epigastric  angle,  16. 

Epigastric  enlargement,  differentiation 
of  nature  of,  375. 

Epigastric  pulsation,  226. 

Epigastrium,  systolic  recession  of,  228. 

Epilepsy  associated  with  bradycardia, 
321. 

Equilibrium,    elastic,    of    air-vesicles, 
119. 

Equipment  of  physician,  physical  and 
psychic,  9. 

Erector  spina?  muscles,  15. 

Examination,  physical,  results  of,  3. 

Exercise,  influence  of,  on  heart  mur- 
mur, 298. 

Exhaustion,  general,  as  cause  of  car- 
diac weakness,  270. 

Exophthalmic  goiter,  314. 
murmur  of,  359. 

Expiration,  forced,  pitch  of,  93. 
jerky,  60. 
prolongation  of,  60,  157. 

"Expiratory  drag,"  65. 

Expiratory    pressure,    diminution    of, 
58. 

Expiratory  sound,  delayed,  157. 

Exploratory  puncture,  195. 

Extrapulmonary  conditions,  113. 

Extremities,  bulkiness  of,  372. 

Exudation,  pleuritic,  113. 

determination  of  nature  of,  196. 
its  relation  to  percussion  dulness, 
113. 

Fat,  abdominal,  372. 

simulating  liquid,  373. 
Fatty  degeneration,  weak  heart  sounds 

of,  270. 

Febrile    diseases    causing    splenic    en- 
largement, 404. 

Fecal  accumulations,  376,  377. 
palpation  of,  388. 
simulating  enlarged  spleen,  404. 
Femoral  veins,  venous  murmur  in,  347. 
Fermentation,  gastric,  387. 
Fetal  remnant  in  umbilical  region,  377. 
Fetal  rhythm,  277. 
Fevers,  acute  infectious,  arrhythmia  of, 

277. 

prolonged,  toxemias  of,  270. 
Finger,  hyperemia  of,  from  percussion, 

81. 

Finger  percussion,  246. 
advantages  of,  75. 
baring  of  chest  for,  76. 


440 


INDEX 


Finger  percussion,  method  of,  76. 

position  of  the  patient  for,  76. 
Finger-friction  sounds,  144. 
Fingers,  clubbing  of,  353. 
Fissures  of  the  lungs,  20,  21,  25. 

long  or  greater,  25. 

short  or  lesser,  25. 
Fistula,  thoracic,  128. 
"Flint"  murmur,  292,  356,  359. 
Fluctuation,  abdominal,  373. 

in  precordial  interspaces,  244. 

peripheric,  71. 

simple,  elicited  by  palpation,  71. 
"Fluid  veins,"  283. 
Fluorescent  screen,  417,  418,  423. 
Fluoroscope,  use  of,  419,  426,  427. 
Flush  streak  on  forehead,  340. 
Fontanelle  of  infants,  systolic  cerebral 

blowing  sound  in,  339. 
Foot,  venous  pulse  in,  346. 
Fractures  as  cause  of  asymmetry  of 

chest,  30. 

Fremissement  cataire,  242. 
Fremitus,  189. 

bronchial  or  rhonchal,  70. 

cavernous,  71. 

intensity  of,  regional  differences  in,  67. 

pectoral,  65,  68. 

pleural  or  friction,  disappearance  of, 
69. 

succession  or  splashing,  71. 

tactile,  65. 
in  adults,  67. 

tussive,  71. 

vocal,  examination  of,  65. 

variations  in,  191. 

Friction  fremitus,  pericardial,  236,  244. 
Friction,  pleuropericardial,  184. 

subpleural,  183. 
Friction  sounds,  283,  308. 

due  to  perihepatitis,  183. 

in  peritoneum,  380. 

over  spleen,  407. 

pericardial,  310. 

pleuritic,  168,  180. 

of  leathery  character,  181. 

pleuropericardia1,  311. 

study  of,  144. 

triple,  309. 

Friedreich's  change  of  sound,  123. 
Funnel  breast,  47. 
Furrow,  peripneumonic,  210. 

Gall-bladder,  displacement  of,  380. 
distention  of,  375,  376,  380. 

causes  of,  396. 

differential  diagnosis  of,  397. 
malignant  growths  in,  396. 
palpation  of,  396. 
position  of,  392. 
range  of  mobility  of,  397. 
tumor  of,  377. 


Gallop  rhythm,  diseases  in  which  it  is 

a  danger  signal,  279. 
Gall-stones,  396. 

crepitus  of,  401. 

recognized  by  Rontgen  rays,  428. 
Gangrene  of  lung,  120,  164. 

percussion  dulness  in,  111. 
Gastrectasis,  374,  382. 
Gastric  tympany,  enlarged  area  of,  386. 
Gastric  walls,  increased  resistance  of, 

383. 

Gastritis,  epigastric  tenderness  in,  383. 
Gastrointestinal  tract,  Rontgen  exam- 
ination of,  427. 
Gastroptosis,  374,  377,  382. 
Gerhardt's  change  of  pitch,  123,  127. 
Glands,  enlargement  of,  in  Hodgkin's 

disease,  375,  377. 

mesenteric  or  retroperitoneal,  375. 
Glenard's  disease,  413. 
Glottic  vibrations,  transmission  of,  188. 
Glottis,  widening  of,  123. 
Goat  voice,  192. 
Goiter,  exophthalmic,  232,  277. 
Grayes's  disease,  232. 
"Grip,"  indeterminate  breathing  in,  160. 
Grocco's  paravertebral  triangle,  115. 
Groove  from  navel  to  ribs,  382. 
Growth,  hydronephrotic,  409. 
Gurgles,  172. 

cavernous,  absence  of,  172. 

ileo-cecal,  390. 

in  right  iliac  region,  388. 
Gymnastics,  respiratory,  57. 
Gymnasts,  vital  capacity  necessary  for, 
57. 

Hair,  loss  of,  418. 

Hammer-pleximeter  percussion,  194. 
Hand,  venous  pulse  in,  346. 
Harrison's  sulcus,  46. 
Health,   vigor  of,   its  effect  on  valve 

sounds,  267. 
Heart,  anatomy  of,  clinical,  214. 

topographic  and  relational,  214. 
anterior  surface  of,  216. 
auricles  of,  217. 
auscultation  of,  dorsal,  287. 
basal  beat  of,  223. 
base  of,  anatomic,  217. 

clinical,  217. 

boundaries  of,  216,  218,  251,  252. 
bovine,  231. 
chest  outlines  of,  effect  of  posture 

upon,  220. 
effect    of    respiratory    movement 

upon,  220. 

congenital  anomalies  of,  306. 
dilation  of,  229,  253,  273,  355,  426. 
hypertrophic,  221. 
with  weakened  ventricular  walls, 
272. 


INDEX 


441 


Heart,  disease  of,  actual  and  hypothet- 
ical cases  of,  348. 
physical  diagnosis  of,  214. 
valvular,  209. 
displacement  of,  50,  225,  229,  426. 

rhythmic  lateral,  235. 
fatty  degeneration  of,  240,  272. 
first  and  second  sounds  of,  260. 
four  sounds  of,  263. 
highest  point  of,  216. 
hypertrophy  of,  163,  225,  229,  240, 

253,  273,  311,  314,  426. 
apparent,  256. 
sounds  in,  270. 
with    loss  of  compensation,   270, 

272. 

inspection  of,  221. 
intermittent,  234. 
location  of,  20,  214,  245. 

normal,  426. 
musical,  307. 
neighborhood    of,     dissimilarity    of 

percussion  sounds  in,  102. 
normal,  mobility  of,  220. 
percussion  of,  245. 
surface  landmarks  of,  216,  220. 
obstruction   of   flow   of  blood   into, 

271. 

paralysis  of,  279 
pulsating,  shadow  of,  420. 
pulsations  of,  55. 

at  base  and  borders,  223. 
relations  of,  to  chest  wall,  216,  217. 

to  lungs,  218. 

Rontgen  examination  of,  426. 
shape  of,  245. 
size  of,  245,  249,  426. 
true  apex  of,  251. 
valves  of,  264. 
valvular  disease  of,  277. 
ventricles  of,  217. 
weak,  279,  336. 
diagnosis  of,  233. 
hypostasis  of,  111. 
Heart  dulness,  absence  of,  130. 
Heart  failure,  273. 
Heart   muscle,   granular   degeneration 

of,  272. 

Heart  sound,  first,  accentuation  of,  270. 
diminished  intensity  of,  272. 
slapping  character  of,  271. 
mitral,  accentuation  of,  271. 

muffling  of,  271. 
second,    clanging,    booming   quality 

of,  269. 

reduplication  or  division  of,  269. 
tricuspid,  271. 
Heart   sounds,    accentuation   of,    261, 

268,  270,  276. 
causes  of,  261,  262. 
changes  in  intensity  of,  270. 
character  of,  259. 


Heart  sounds,  elevation  of,  276. 
heard  through  stethoscope,  143. 
in  aortic  regurgitation,  358. 
in  mitral  obstruction,  354. 
metallic  quality  of,  269. 
normal,  260. 

pathologic  modifications  of,  269. 
physiologic  variations  in,  267. 
pitch  of,  268,  276. 
produced  at  four  valve  areas,  267. 
rhythm  or  time  of,  261,  263. 
showing  irritability  of  weakness,  271. 
strength  and  loudness  of,  267. 
Heart  strength  indicated  by  force  of 

pulse,  323. 

Heart-lung  boundary,  245. 
Heart-murmurs,  valvular,  8. 

simulated    by    systolic    vesicular 

breathing,  152. 
Hematocele,  pelvic,  376. 
Hematoma,  377. 
Hemisystole,  241. 
Hemorrhage,  avoidance  of  percussion 

after,  81. 

severe,  cardiac  effect  of,  274. 
Hemothorax,  69,  425. 
Hepatic  dulness,  130. 
Hepatic  flexure,  distention  of,  causes 

of,  376. 

Hepatitis,  diffuse  syphilitic,  395. 
Hernia,  epigastric,  372. 
inguinal,  376. 
umbilical,  372,  377. 
Hippocratic  succussion  sound,  132,  186. 
Hodgkin's  disease,  375,  404. 
abdominal  glands  in,  377. 
Hydatid  thrill,  396. 
Hydatids  of  liver,  377,  393,  395,  396. 

of  spleen,  404. 
Hydremia,  298. 
Hydropericardium,    mobile    transuda- 

tion  of,  256. 

Hydropneumopericardium,  311. 
Hydropneumothorax,  71,  213,  425. 
detection  of,  72. 
metallic  tinkling  in,  185. 
percussion  dulness  in,  115. 
Hydrops  of  gall-bladder,  396. 
Hydrothorax,  69. 

percussion  dulness  in,  115. 
Hyperpnea,  59. 
Hyperresonance,  92,  93,  130. 
in  emphysema,  116. 
unilateral,  116. 
Hypochondriac  region,  position  of  liver 

in,  391. 
Hypopnea,  59. 
Hypostasis,  differentiation  of  physical 

signs  of,  207. 
Hypostatic  congestion,  207. 

transition  of,  into  pulmonary  edema, 
208. 


442 


INDEX 


Hysteria,  altered  respiration  in,  51, 151. 
aortic  pulsations  in,  378. 

Infarcts,  crepitant  rales  in,  178. 
hemorrhagic,  162,  208. 
localization  of,  209. 
percussion  dulness  in,  110,  111. 
revealed  by  pleuritic  friction,  183. 
Infraclavicular    spaces,    percussion   of, 

99. 
Inframammary  regions,  contents  of,  21. 

percussion  of,  100. 
Infrascapular    regions,    percussion    of, 

101. 

Inguinal  region,  363. 
Innominate  artery,  position  of,  218. 
Inspection  of  chest,  method  of,  28. 
posture  for,  28. 
preferable  light  for,  28. 
Inspiration,  increased  length  of,  60. 
irregular  rhythm  of,  60. 
jerky,  interrupted,  or  wavy,  151. 
Inspiration   and    expiration,    compari- 
son of  movements  of,  150. 
lengthened  interval  between,  156. 
Inspiration-expiration    ratio,    changed 

relation  of,  60. 
Inspiration     to     expiration,      relative 

length  of,  145. 
Inspiratory    pressure,     diminished    in 

tuberculosis,  58. 

Inspiratory  sound,  shortened,  157. 
Insufficiency,  tricuspid  and  mitral,  301. 
Intercostal  depressions,  237. 
Intercostal  spaces,  location  of,  14,  16. 
lower  antero-lateral,  recession  of,  53. 
movements  of,  32. 
second  right,  265. 

Interscapular  region,  percussion  of,  101. 
Intestinal  neoplasms,  mobility  of,  389. 
Intestinal  obstruction,  peristalsis  in, 

388. 

Intestinal  sounds,  variety  of,  390. 
Intestine,  large,  percussion  outline  of, 

389. 

Intestines,  areas  of  dulness  over,  390. 
examination  of,  388. 

Rontgen,  427. 
peristaltic  motion  of,  389. 
position  of,  388. 
topographic  anatomy  of,  388. 
Intrapulmonary  conditions,   109. 
"India-rubber-ball"  sound,  195. 

Jaundice,  significance  of.  (See  Table 
on  Diagnosis  of  Diseases  of  the 
Liver,  bet.  pp.  396-97.) 

Jugular  bulb,  341. 

Jugular  pulse,  normal,  343. 

Jugular  undulations,  341. 

Jugular  veins,  as  indices  of  venous  cir- 
culation, 340. 


Jugular  veins,  diastolic  collapse  of,  345. 
distention  of,  abnormal,  341. 
pulsation  of,  243. 
visibility  of,  340. 

Katzenschniirren,  242. 
Kidney,  boggy  resistance  over,  410. 
cystic,  377. 
displaced,  floating,  or  movable,  376, 

377,  409. 
diagnosis  of,  428. 
differentiated  from  spleen,  412. 

from  tumor  of  gall-bladder.  397. 
palpation  of,  376. 
enlargement  of,  376,  409. 
palpation  of,  409. 

as  a  "greasy  mass,"  409. 
without  dislocation,  410. 
percussion  of,  411. 
range  of  mobility  of,  397. 
sarcoma  of,  in  children,  410. 
tumor  of,  with  bulging,  409. 
Kidney  and  bowel,  relation  of,  410. 
Kidney  dulness,  398. 
Kidneys,  anatomy  of,  topographic,  407. 
examination  of,  428. 
location  of,  on  the  back,  408. 
shape  and  surface  of,  410. 
Kyphoscoliosis,  48. 
Kyphosis,  47. 

Landmarks,  anatomic,  27. 

arbitrary  lines  as,  17. 

of  the  lungs,  24. 

Laryngeal  whisper,  normal,  189. 
Laryngophony,  188. 
Larynx,  in  relation  to  vocal  fremitus, 

66. 
Lead-poisoning,    double    murmur    in, 

338. 

Life-insurance,  importance  of  respira- 
tory expansion  in,  36. 
Lime  salt  deposits,  314,  318. 
Linea  alba,  366. 

Linea  costo-articularis,  37,  406. 
Linese  albicantes,  369 
Linese  semilunares,  366. 
Linese  transverse,  366. 
Lines,  bispinal  and  subcostal,  363. 

vertical  or  longitudinal,  used  in  de- 
scribing physical  signs,  17,  18. 
Lip  murmur,  146. 
Lipoma,  abdominal,  372. 
Litten's  sign,  32. 

absence  of,  58. 
significance  of,  33. 

as  indication  of  respiratory  capacity, 
58. 

in  hypertrophic  emphysema,  210. 

value  of,  in  differential  diagnosis,  58. 
Liver,  abscess  of,  395,  399. 

amyloid,  395. 


INDEX 


443 


Liver,  anatomy  of,  topographic,  391. 

antero-inferior  edge  of,  391. 

atrophy  of,  400. 

auscultatory  percussion  of,  399. 

borders  of,  conditipn  of.  (See  Table 
on  Diagnosis  of  Diseases  of  the 
Liver,  bet.  pp.  396-97.) 

bosselated,  396. 

cancerous,  395. 

conditions  affecting  edge  of,  395. 

consistency  of.  (See  Table  on  Diag- 
nosis of  Diseases  of  the  Liver, 
bet.  pp.  396-97.) 

diminution  in  size  of.  (See  Table  on 
Diagnosis  of  Diseases  of  the 
Liver,  bet.  pp.  396-97.) 

diseases  of,  diagnosis  of.  (See  Table 
on  Diagnosis  of  Diseases  of  the 
Liver,  bet.  pp.  396-97.) 

displacement  of,  393,  394,  399,  400. 

effects  of  tight  lacing  on,  394. 

engorgement  of,  passive,  395. 

enlargement  of,  230,  375,  393,  399, 

400. 

from  amyloid  or  fatty  degenera- 
tion, 393. 
from  leukemic  or  malarial  hyper- 

plasia,  393. 
uniform  or  irregular,  393. 

examination  of,  by  inspection,  392. 

fatty,  395. 

floating,  377. 

form  of,  394. 

hydatid  cyst  of,  399. 

influence  of  age  upon,  392. 

leukemic,  395. 

lobulated,  396. 

nodular,  395,  396. 

pain  in.  (See  Table  on  Diagnosis  of 
Diseases  of  the  Liver,  bet.  pp. 
396-97.) 

palpation  of,  393. 

percussion  of,  397. 

position  of,  391. 

pulsation  of,  227. 
vascular,  369. 

Rontgen  examination  of,  428. 

senile  shrinkage  of,  398. 

shadow  of  lower  edge  of,  393. 

size  of,  392,  394. 

surface  of,  granular,  395. 

smooth  or  uneven,  395.  (See  also 
Table  on  Diagnosis  of  Diseases  of 
the  Liver,  bet.  pp.  396-97.) 

surfaces  of,  391. 

syphilitic,  395. 

tumor  of  convexity  of,  399. 

wandering,  393,  394,  400. 
Liver  and  spleen,  line  of  demarcation 

between,  56. 
Liver  dulness,  absence  of,  400. 

absolute,  397. 


Liver  dulness,  areas  of,  397,  399,  400. 
borders  of,  398. 
extent  of,  normal,  411. 
relative,  397,  400. 
Liver  pulse,  venous,  345. 
Liver-kidney  angle,  411. 
Logic  as  a  fundamental  science,  6,  8. 

as  a  necessity  in  diagnosis,  8. 
Lordosis,  48. 
Lung,  cardiac  border  of,  retraction  of, 

131. 
cavities    in,    indicated    by    whisper 

pectoriloquy,  192. 
large,    tense-walled,    communicat- 
ing, 193. 
collapse  of,  160,  424. 

from  pleuritic  effusion,  192. 
compression  of,  129,  162,  191. 
congestion  of,  203. 
consolidation  of,  68,  109,   124,  161, 

183,  240,  425. 
physical  changes  in,  158. 
resonant  rales  in,  176. 
shadow  of,  421. 
small  or  partial,  111,  191. 
tuberculous,  112. 
expansion    of,    after   application    of 

irritant,  129. 
conditions   which   interfere   with, 

154. 

fibroid  contractions  of,  230. 
hemorrhagic  infarct  of,  110. 
large  and  air-containing,  212. 
left,  chronic  fibroid  contraction  of, 

230. 

fissure  of,  25. 
limits  of,  24. 
lingula  of,  25. 

lobes  of,  fissure  between,  20,  21. 
malignant  vascular  tumor  of,  226. 
normal  percussion  limits  of,   104. 
overlapping  heart,  270. 
percussion  of,  when  removed  from 

body,  87. 
pneumonitic,  128. 
pulsatile  movement  of,  72. 
relaxation  of,  93,  119. 
resonance  of,  93. 
retraction  of,  93,  119,  124,  129,  131, 

191,  240,  313. 
over  normal  heart,  256. 
right,  less  resonant  than  left,  97. 

limits  of,  24. 
Rontgenography  of,  419. 
solid  growths  on  or  near,  110. 
transparency  of,  in  Rontgenogram, 

423. 

tuberculous  condensations  of,  191. 
Lung  and  pleura,  fistulous  communica- 
tion between,  122. 

Lung  boundaries,  altered  condition  of, 
130. 


444 


INDEX 


Lung  boundaries,  apparent  unilateral 

expansion  of,  131. 
displacements  of,  107. 
extension  of,  bilateral,  130. 

unilateral,  131. 
mobility  of,  130. 

diminished,  131. 
position  of,  130. 
Lung  capacity,  in  relation  to  height,  40. 

of  young  adults,  57. 
Lung  reflex,  129. 
Lung  sounds,  differing  from  adjacent 

tissues,  103. 

Lung  structure,  shadows  of,  420. 
Lung  tissue,  destruction  of,  by  various 

diseases,  119. 
solidification  of,  162. 
Lung-fistula  sound,  186. 
Lung-liver  boundaries,  384. 
Lungs,  anterior  borders  of,  delimitation 

of,  104. 
apices  of,  19. 

difference  in  percussion  note  of, 

102. 

disease  of,  110. 

areas  of  disease  in,  revealed  by  per- 
cussion, 108. 

damming  back  of  blood  in,  275. 
determinable  percussion  outlines  of, 

104,  106. 

differences  between,  24. 
diseases    of,    physical    diagnosis    of, 

199. 

edema  of,  178. 
lobes  of,  26. 
mobility  of,  107. 
percussion  of,  affected  by  proximity 

of  heart  and  liver,  95. 
technic  of,  97. 
position  of  lobes  of,  26. 
proximity  of,  to  parieties,  103. 
pyemic  deposits  in,  183. 
relational  anatomy  of,  24. 
size  of,  103. 

superior  border  of,  elevated  on  ex- 
piration, 105. 
volume  of,  92. 

"volumetric  variation"  of,  62. 
Lungs  and  adjacent  organs,  boundaries 

of,  103. 

Lungs  and  pleurae,  diseases  of,  hypo- 
thetical cases  of,  199. 
Lung-stomach  boundaries,  384. 
Lymph  glands,  enlargement  of,  338. 

Mammae,  sensitiveness  of,  252. 
Mammary  glands,   large,  influence  of, 

on  heart  sounds,  267. 
location  of,  16. 

Mammary  regions,  right  and  left,  con- 
tents of,  20. 
percussion  of,  100. 


Mammillary  lines,  18. 
Maneuver,  arm,  182. 

decubital,  182. 
Meal,    full    and    stimulating,    cardiac 

effect  of,  23£. 

Mediastinopericarditis,  fibrous,  341. 
Mediastinum,  solid  growths  of,  230. 

tumors  of,  427. 

Medical  examiners,  physical  examina- 
tion by,  35. 
Medical  physics,  6. 
Men,  type  of  respiration  in,  31. 
Mensuration,  spirometric,  57. 

thoracic,  34. 

Mesenteric  glands,  enlargement  of,  377. 
Mesoaxillary  (midaxillary)  line,  15,  18. 
Mesocardia,  258. 

Mesoclavicular  (midclavicular)  line,  18. 
Mesospinal  (midspinal)  line,  18. 
Mesosternal  (midsternal)  line,  18. 
Metallic  tinkling,  185,  186. 
Meteorism,  373. 

displacing  apex-beat,  229. 
Microscopy,  clinical,  6. 
Mitral  insufficiency,  225,  275. 

back  flow  of  blood  in,  275. 

organic,  diagnosis  of,  353. 
differential  diagnosis  of,  351. 

physical  pathology  of,  350. 

relative,  351. 

murmur  of,  352. 

Mitral  obstruction,  physical  pathology 
of,  355. 

physical  signs  in  a  case  of,  353. 
Mitral    regurgitant    murmur,    relative, 

352. 
Mitral  regurgitation,  324,  355. 

slight  degree  of,  353. 
Mitral    stenosis,    225,   275,    280,   324, 
353. 

circumscribed  dulness  in,  255. 

differentiated     from     regurgitation, 
355. 

heart  sound  in,  271. 
Mitral  thrills,  presystolic  and  systolic, 

242. 
Mitral  valve,  219. 

closure  of,  264. 

insufficiency  of,  350. 

lesions  of,  274. 

Mobility  of  lungs,  postural  or  passive, 
107. 

respiratory  or  active,  107. 
Moderator  bands,  307. 
Morenheim's  depression,  20,  50. 
Mouth-breathers,  chest  of,  42. 
Mucous  click,  169,  180. 
Murmur,  aortic  diastolic  or  regurgitant, 
293. 

aortic  obstructive,  300. 

aortic  regurgitant,  356. 
transmission  of,  301. 


INDEX 


445 


Murmur,  aortic  systolic,  288,  293,  300. 

differentiated  from  aortic  regurgi- 

tant,  359. 

diastolic  functional,  305. 
double,  338,  359. 
Duroziez's,  338. 
endocardia!,  282,  310. 

functional  or  dynamic,  282. 

hemic  or  anemic,  282. 

organic  or  structural,  282. 
late  systolic,  288. 
mitral  diastolic,  290. 
mitral  obstructive,  359. 
mitral  presystolic,  290,  292. 

appearance  and  disappearance  of, 

297 

mitral  systolic,  291,  300,  301. 
obstructive  aortic,  288. 
over  dilated  aorta,  359. 
over  liver,  401. 
presystolic,  288. 
pulmonic  diastolic,  295. 
pulmonic  systolic,  295. 
regurgitant,  284,  286. 

aortic,  288,  289. 

mitral,  288. 
"seesaw,"  301. 
systolic,  288. 

aortic,  288. 

mitral,  288,  360. 

presystolic,  290,  295. 

regurgitant,  290. 
tricuspid,  294. 
vesicular,  in  children,  150. 
Murmurs,  242,  259. 
accidental,  304. 

characteristics  of,  304. 

location  of,  306. 

musical,  307. 

production  of,  305. 
anemic,  304,  305,  352,  359. 
aneurismal,  283,  359. 
arterial,  337,  338. 

associated  with  cardiac  neuroses,  303. 
blowing  or  rustling,  296. 
cardio-muscular,  304. 
characteristics  of,  285. 
chlorotic,  306. 

differentiation  of  significance  of,  300. 
direct  or  onward,  283. 
due    to    disease    of    arterial   walls, 

338. 

duration  of,  298. 
dynamic,  304. 

of  health,  304. 

functional,  303,  306,  351,  359. 
functional  and  organic,  differentiation 

of,  306. 

hemic,  286,  304,  305. 
indeterminate,  145. 
induced  or  pressure,  337. 
inorganic,  304. 


Murmurs,  intensity  of,  296. 

influenced  by  posture,  exercise,  and 

respiration,  298. 
interpretation  of,  299. 
localization  of,  285. 
mode  of  eliciting,  288. 
multiple  or  combined,  299. 
musical,  296,  297,  307. 
of  insufficiency,  when  heard,  287. 
of  obstruction  or  stenosis,  283,  287. 
of   pulmonary    valve,    systolic    and 

diastolic,  290. 
organic  valvular,  rhythm  of,  287. 

transmission  of,  290. 
pericardial,  308. 

pericardial  and  endocardial,  differen- 
tiation of,  310. 
physical  diagnosis  of,  288. 
physical  explanation  of,  283. 
production  of,  283. 
quality  and  intensity  of,  295. 
relation  of,  to  normal  heart  sounds, 

_288. 
respiratory,  study  of,  144. 

vesicular  and  bronchial,  145. 
rumbling  or  rasping,  296. 
twanging  and  singing,  296. 
venous,  305. 

Muscle  sounds,  144,  187. 
Muscles,   inspiratory,  tetanic  contrac- 
tion of,  61. 

recti,  separation  of,  372. 
Muscular  development,  larger,  of  right 

side,  101. 

Myocardial  degeneration,  277,  323. 
Myocarditis,  240. 
murmur  of,  359. 
weakened  heart  sound  in,  270,  272. 

Nails,  loss  of,  418. 

Neck,  throbbing  in,  314. 

Neoplasms,  abdominal,  372. 

causing  splenic  enlargement,  404. 

Nephritis,  chronic,  240. 
chronic  interstitial,  273. 

Nervous   system,   effect   of,   on   valve 
sounds,  268. 

Neurasthenia,   exaggerated  aortic  im- 
pulse in,  227. 

Nipple,  location  of,  16,  18. 

Notches,  epi-  and  suprasternal  pulsa- 
tion  in,  313. 

Obesity,  372. 

Occupation,    as    cause    of    abnormal 

thorax,  30. 

influence  of,  on  valve  sounds,  268. 
Omental  adhesion,  377. 
Omentum,  shrinking  and  thickening  of, 

377. 

Ophthalmology,  5. 
Organography,  3. 


INDEX 


Orifices,  mitral  and  tricuspid,  267. 

non-valvular,  285. 
Orthopnea,  cardiac,  62. 

relieved  by  upright  posture,  62. 

Osseous  and  cartilaginous  framework, 

influence  of,  on  percussion,  87. 
resilience  of,  87. 
Ovary,  tumor  of,  377. 

Pain,  cardiac,  after  pneumonia,  423. 
Palpation,  in  ticklish  patients,  371. 

of  apex-beat,  344. 

of  chest,  6,  63. 

preparation  of  hands  for,  63. 

value  of,  63,  236. 
Palpatory  percussion,  246. 
Palpitation,  nervous,  232. 
Pancreas,  cancer  of,  375,  397. 

cyst  of,  375. 
Pantograms,  39. 
Pantograph  of  Hall,  38,  42. 
Parasternal  lines,  18. 
Pathology  as  a  fundamental  science, 

6,7. 
Pectoriloquy,  190. 

whisper,  192. 
Pectus  carinatum,  46. 
Pelvimeter,  Collyer's,  37. 
Pelvis,  enlargements  of,  376. 
Percussion,  6. 

abdominal,  technic  of,  378. 

aim  and  result  of,  108. 

auscultatory,  82,  84,  385. 
advantages  of,  84. 
technic  of,  386. 

by  finger-pleximeter,  81. 

by  hammer-pleximeter,  81. 

cardiac,  methods  of,  246,  249. 

comparative,  of  two  sides,  77. 

contraindication  to,  80. 

definition  of,  74. 

direct,  74. 

faulty  method  of,  78. 

for     detection     of     deeply     seated 
growths,  82. 

forcible  or  gentle,  79. 

fundamental  principle  of,  73. 

history  of,  73. 

immediate,  advantages  of,  74. 

in  children,  80. 

in  the  emaciated,  80. 

in  the  muscular  and  the  fat,  79. 

indirect,  74,  75. 

intestinal,  94,  389. 

mediate,  74,  75,  76. 
palpatory,  73. 

methods  of,  74,  82,  252. 

modifying  factors  in,  77. 

of  chest,  in  front  and  back,  77. 
lateral  and  axillary  regions  of,  77. 

of  left  side,  100. 


Percussion  of  stomach,  87,  94. 

palpatory,  84. 

position  of  examiner  for,  78. 

prolongation  of,  over  one  spot,  79. 

respiratory,  82. 

sensation  of  resistance  elicited  in,  84. 

stethoscopic,  82. 

stroking,  386. 

superficial  and  deep,  85. 

topographical,  73,  77,  87,  103. 

variations  in  force  of,  80. 

vibration  of  underlying  parts,  84. 

with  four  fingers,  78. 

with  open  or  closed  mouth,  122. 
Percussion  boundaries,  lung-heart,  105. 

lung-kidney,  106. 

lung-liver,  106. 

lung-spleen,  106. 

lung-stomach,  106. 
Percussion  dulness,  absolute,  111,  130. 

in  aortic  regurgitation,  357. 

"wooden"  quality  of,  113. 
Percussion  hammer  of  Wintrich,  76. 
Percussion  movement,  springing  from 

the  wrist,  78. 
Percussion  note  "box  tone"  of,  211. 

clearness  of,  on  light  stroke,  78. 

tympanitic,  378. 

Percussion  sounds,  abnormal,  diagnos- 
tic significance  of,  108. 
physical  explanation  of,  108. 

amphoric,  121. 

attributes  of,  85,  86. 

cavernous,  121. 

dulness  of,  85,  89,  109. 
relative,  85,  89,  90. 

duration  of,  86,  96. 

impaired  resonance  of,  85. 

intensity  or  volume  of,  86,  90. 

modified  by  intervening  bone,  87. 

normal  variation  in,  97,  102. 

over  stomach  distended  with  air  or 
gas,  90. 

pitch  of,  86,  91 

quality  of,  86. 

thoracic,  85. 
Percussion  stroke,  force  of,  79. 

manner  of  delivery  of,  79. 
Percussion-wave,  331. 
Pericardia!  effusions,  117,  426. 

as  cause  of  bronchial  breathing,  163. 
of  elastic  equilibrium  of  lung,  119. 
of  precordial  bulging,  222. 

displacing  apex-beat,  229. 

displacing  heart,  270. 

impeding  action  of  diaphragm,  52. 

lessened  apex-beat  in,  240. 

shown  by  cardiac  dulness,  255. 
Pericardial  friction  differentiated  from 

mitral  stenosis,  356. 
Pericardial  murmurs,  308. 

location  of,  309. 


IXDEX 


447 


Pericardial  murmurs,  loudness  of,  310. 
quality  of,  309. 
rhythm  of,  309. 

Pericardial  splashing  sounds,  311. 
Pericarditis,  240. 
mediastinal,  330. 
simple  fibrinous,  310. 
Pericardium,  adherent,  222,  226,  241. 
changed  heart  sounds  in,  270. 
murmur  due  to,  359. 
diseases  of,  214. 
Perihepatitis,  380,  400. 
Perisplenitis,  380,  407. 
Peristalsis,  vermicular  movements  of, 

378. 

Peristaltic  movements  of  stomach,  382. 
"Peristaltic  unrest,"   383. 
Peristaltic  waves,  383. 
Peritoneal   cavity,   ruptured  ulcer  of, 

378. 

Peritoneal  effusion,  375. 
Peritonitis,  extreme  distention  of,  389. 
subphrenic,  380. 
tuberculous,  377,  395. 
Phonendoscope,  83. 

in  physical  diagnosis,  140. 
of  Bazzi  and  Bianchi,  140. 
Phthisis,  119.     See    also    Tuberculosis. 
acute  pneumonic,  208. 
acute  tuberculopneumonic,  208. 
fibroid,  113. 

with  thickened  pleura,  193. 
flat  chest  of,  43. 

Physical  diagnosis,  as  a  science,  5. 
benefits  from  the  study  and  practise 

of,  9. 

qualifications  for  the  study  of,  9. 
relations  of,  6. 

standpoint  and  importance  of,  3. 
Physical  examination,  visible,  palpable, 

and  audible  results  of,  3. 
Physical  exercise,  effect  of,  on  apex- 
beat,  239. 
Physical  phenomena,  ante-mortem  and 

post-mortem,  comparison  of,  7. 
Physical    signs,    significance    of,  4,  6, 

196. 

clear,  doubtful,  absent,  196. 
combination  of,  196. 
comparison  of,  196. 
elicited    by    feeling    of     the     chest 

walls,  6. 
in  health,  5. 

methods  for  perception  of,  196. 
Physical  strain,  effects  of,  357. 
"Physiognomy  of  disease,"  3. 
Physiologic  activity,  effect  of,  on  veins, 

340. 

"Physiological  heteromorphisms,"   30. 
Physiology  as  a  fundamental  science, 

6,  7. 
Pigeon-breast,  45. 

32 


Pitch,  alterations  of,  158. 

high,  associated  with  hyperresonance, 
117. 

in  cardiac  percussion,  250. 

influence  of  chest  wall  upon,  93. 

of  right  and  left  lungs,  95. 

production  and  variation  of,  92. 

regional  differences  of,  102. 

relation  of,  to  sound,  146. 
Pitting  on  palpation,  72. 
Plegaphonia,  194. 
Plethora,  319. 
Plethoric  habit,  341. 
Pleura,  adherent  to  pericardium,  423. 

exploratory  puncture  of,  195. 

lower  posterior  limit  of,  26. 

tapping  of,  dry,  195. 

thickening  of,  112,  113,  424. 
Pleurae.     See  Pleural  Sacs. 
Pleural  cavity,  fluid  in,  112. 
Pleural  effusion,  193,  230. 

as  cause  of  absence  of  fremitus,  69. 

differential  diagnosis  of,  56,  196. 

displacing  heart,  270. 

displacing  liver  dulness,  400. 

Grocco's   paravertebral   triangle,    in 
115. 

left-sided,  230. 

lessened  apex-beat  in,  240. 

moderate-sized,  192. 

percussion  dulness  in,  113. 

physical  diagnosis  of,  56. 

production  of,  182. 

Rontgenogram  of,  424. 

simulating  pneumonic  consolidation, 
208. 

unilateral,  235. 

with  apparent  symmetry  of  chest,  50. 

with  lung  consolidation,  425. 
Pleural  membranes  and  sacs,  disease  of, 

ascertained  by  percussion,  109. 
Pleural  sacs,  diseases  of,  physical  diag- 
nosis of,  199. 

malignant  growths  in,  163. 

relational  anatomy  of,  26. 
Pleural  sinuses,  complemental,  27. 
Pleurisy,  Pleuritis,  acute,  54. 

adhesive,  131,  230. 

diaphragmatic,  183. 

dry  tubercular,  180. 

localized,  155. 

sicca,  181. 

with  effusion.    See  Pleural  Effusion. 

with  thickening  of  membranes,  193. 

with  unilateral  restriction  of  move- 
ment, 54. 

Pleuritic   friction,    differentiated   from 
bronchial  rales,  183,  184. 

disappearance  of,  182. 

diseases  revealed  by,  183. 

elicited  by  maneuvers,  182. 

location  of,  180. 


448 


INDEX 


Pleuritic  friction,  pitch  and  duration  of, 

181. 

quality  and  intensity  of,  181. 
Pleuropneumonia,  191,  206. 

pleuritic  element  of,  unnoticed,  184. 
Pleximeter,  double,  of  Seitz,  76. 
invention  of,  73. 
of  Piorry,  75. 
of  Sansom,  76,  81. 
Pleximeter  finger,  77,  78,  250. 
Pleximetric  percussion,  246,  252. 
Plexor,  75. 

Plexor  finger,  proper  flexion  of,  78. 
Pneumatometry,  41,  58. 
Pneumography,  41. 

Pneumonia,  Pneumonitis,  abortive,  206 
acute  croupous,  203. 
acute  lobar,  111. 
apical,  205. 

bronchial  respiration  in,  162. 
catarrhal,  178. 
central,  162,  205. 
chronic  fibroid,  162. 
chronic  interstitial,  113. 
consolidation  of,  89,  191. 
creeping,  205. 

differential  diagnosis  of,  206. 
following  etherization,  206. 
following  surgical  and  accidental  in- 
juries, 206. 
hypostatic,  207. 

invariably  bilateral,  208. 
influence  of  age  upon  physical  signs 

of,  205. 

influenzal,  206. 
lobar,  25,  68. 

acute,  failure  of  right  heart  in,  275. 
crisis  in,  203. 

high-pitched  breathing  in,  161. 
physical    examination    in,    201, 

202. 

recovery  from,  clinical  and  path- 
ological, 204. 

signs  of  danger  in,  275,  276. 
stages  in,  of  congestion,  203. 
stages  in,  of  consolidation,  208. 
stages  in,  of  gray  hepatization, 

204. 
stages  in,   of  red  hepatization, 

203. 

stages  in,  of  resolution,  204. 
as  cause   of   bronchial   breathing, 

162. 
synthetic  analysis  of  symptoms  of, 

202. 

variations  in  physical  signs  of,  204. 
location  and  extent  of  consolidation 

in,  205. 

masked  by  enlarged  stomach,  205. 
massive,  68,  112,  193,  205. 
of  left  base,  205. 
reactive,  183. 


Pneumonia,  recovery  from,  slow,  423. 
Rontgen  ray  in  the  study  of,  423. 
wandering  or  migratory,  205. 
with  relapses,   205. 
Pneumonokoniosis,  183. 
Pneumopericardium,  257,  269. 
Pneumothorax,  69,  122,  162,  269. 
circumscribed,  192. 
open,  165. 

with  patulous  pleural  opening,  128. 
displacing  liver  dulness,  399,  400. 
effect  of,  on  respiration,  154. 
heart  sounds  in,  270. 
hyperresonance  in,  117. 
intense,  as  cause  of  percussion  dul- 
ness, 115. 

left-sided,  230,  257. 
modes  of  discovering,  126. 
open,  splashing  sound  in,  186. 
recognized  by  Rontgenogram  of,  424. 
right-sided,  230. 
tympanitic  sound  in,  125. 
Poisoning,   by  alcohol  and  strychnin, 

232. 

by  carbonic  acid,  270. 
by  coffee,  tea,  and  tobacco,  232. 
Posture,  change  of,  producing  change  of 

pitch,  127. 
effect  of,  on  apex-beat,  239. 

on  respiration,  32. 
Pott's  disease,  48. 
Poupart's  ligament,  363,  366,  377. 
Precordial  dulness,  upward  increase  of, 

257. 

Precordial  pulsation,  abnormal,  222. 
double,  225. 
significance   of,    in   left   interspaces, 

225. 

in  right  intercostal  spaces,  223. 
in  right  interspaces,  224. 
in  suprasternal  notch,  223. 
over  manubrium,  225. 
synchronous  with  apex-beat,  225. 
Precordium,  areas  adjacent  to,  221. 
auscultation  of,  349. 
boundaries  of,  220. 
bulging  of,  221,  353. 
depression  of,  221,  222. 
inspection  of,  in  heart  disease,  348. 
palpation  of,  236,  349. 
pulsations  within,  221. 
rhythmical  sinking  of,  226. 
systolic  retraction  of,  226. 
Pregnancy,  abdominal  enlargement  of, 

377. 

double  murmur  heard  in,  338. 
extra-uterine,  376. 
simulating  tumor,  374. 
Pressure,   expiratory   and   inspiratory, 

41. 

Presystolic  murmur,  flowing  sound  of, 
298. 


IXDEX 


449 


Prognosis,    dependent    upon    physical 

diagnosis,  8. 

Pubic  region,  enlargements  in,  377. 
Pulmonary     abscess     and     gangrene, 

162. 
Pulmonary  artery,  conus  arteriosus  of, 

225. 

position  of,  217. 
pulsation  of,  313,  315. 
tension  within,  276. 
Pulmonary  cavity,  large,  128. 
of  the  apex,  120. 
shadow  of,  422. 
shape  of,  121. 
size  of,  120. 

tension  of  walls  of,  121. 
tympany  over,  119. 
with  diminished  fremitus,  68. 
with  increase  of  tactile  fremitus,  68. 
Pulmonary  circulation,  congestion  of, 

355. 

rise  of  tension  within,  277. 
Pulmonary  congestion,  acute,  207. 
Pulmonary  disease,  obstructive,  275. 
Pulmonary  edema,  207. 

differentiated  from  lobar  pneumonia, 

208. 

Pulmonary  note  over  ventricle,  247. 
Pulmonary  resonance,  diminished  near 

adjacent  organs,  88. 
dulness  of,  109. 

on  right  side,  99. 
pitch  of,  92. 
Pulmonary  strain,  212. 
Pulmonary  traction,  330. 
Pulmonary  valve,  219. 
Pulmonary    vesicles,    diminished    air- 
space in,  59. 

Pulmonic  sound,  accentuation  of,  274. 
depression  of  pitch  of,  276. 
weakening  of,  275. 
Pulsations,  abnormal,  55,  72,  237. 

in  thorax  and  neck,  340. 
aneurismal,  237. 
aortic  rhythm  of,  227. 
transmission  of,  375. 
carotid,  314,  343. 
dynamic,  237. 
epigastric,  226,  227,  351. 
expansile,  237,  427. 
of  aortic  regurgitation,  314. 
of  innominate  artery,  314. 
of  renal  artery,  397. 
precordial,  222,  245,  353. 
rhythmical  relation  of,  223. 
visibility  of,  223. 
radial,  weakening  and  diminution  in 

size  of,  336. 
venous,  340. 

imparted  or  false,  345. 
Pulse,  acceleration  and  retardation  of, 
320. 


Pulse,      bigeminal      and      trigeminal, 
241. 

bounding,  324. 

capillary,  339. 

beneath  nails,  357. 

character  of,  316,  319. 

compressible,  323. 

conditions  revealed  by,  317. 

examination  of,  316. 

frequency  of,  320. 

high  tension  of,  327,  328. 

intercurrent,  322. 

intermittency  of,  322. 

irregularity  of,  322. 

low  tension  of,  329. 

quality  of,  323. 

rate  of,  319. 

rhythm  of,  321. 

running  or  gaseous,  329. 

soft,  329. 

subungual,  339. 

tension  of,  325. 

thready,  325. 

unilateral  abnormality  of,  336. 

venous,  342. 

volume  of,  324. 
Pulse  tracing,  apex  of,  333. 

as  diagnostic  aid,  332. 

normal,  331. 

pathologic,  332. 

strokes  of,  331,  332,  333. 

tidal  and  dicrotic  waves  of,  333. 
Pulse-wave,  character  of,  317. 

shape  of,  330. 

small,  distinguished  from  weak  pulse. 

318. 

Pulsus  alternans,  241. 
Pulsus  bigeminus,  322. 
Pulsus  bisferiens,  333. 
Pulsus  celer,  330,  332. 
Pulsus  deficiens,  322. 
Pulsus  durus,  325. 
Pulsus  frequens  and  rarus,  320. 
Pulsus  inequalis,  322,  333,  336. 
Pulsus  intercidens,  322. 
Pulsus  intermittens,  322. 
Pulsus  magnus,  324. 
Pulsus  moilis,  325. 
Pulsus  paradoxus,  329,  330 
Pulsus  parvus,  324. 
Pulsus  tardus,  330. 
Pulsus  tremulus,  325. 
Pulsus  trigeminus,  322. 
Pylorus,  cancer  of,  377. 

stenosis  of,  383. 
Pyopneumopericardium,  311. 
Pyopneumothorax,  71. 

metallic  tinkling  in,  185. 

percussion  dulness  in,  115. 

Quadrants,  abdominal,  364. 
Quincke's  venous  pulse,  346. 


450 


INDEX 


"Rachitic  rosary,"  45. 

Rachitis,  deformities  of  chest  in,  45,  46. 

Radial  artery,  condition  of,  congenital, 

318. 

pathologic,  318. 
normal  size  of,  317. 
Radial  pulse-wave,  abortive,  357. 
Radiograph  of  pulmonary  abscess,  422. 

of  pulmonary  gangrene,  423. 
Rales,  168. 
bronchial,  169. 

differentiated   from  pleuritic  fric- 
tion, 184. 
intensity  of,  174. 
irregularity    and    inconstancy    of, 

175. 

location  of,  175. 

variations  and  conditions  modify- 
ing, 174. 
bubbling,  171. 
cavernous,  169. 
character  of,  174. 
consonant  or  ringing,  176. 
crepitant,  176,  177. 
distant,  144. 
dry,  168,  171. 
gurgling,  172. 
indeterminate,  144,  186. 
intrathoracic,  simulation  of,   187. 
large  mucous,   172. 
laryngeal  and  tracheal,  169. 
moist,  171,  172. 

clanging  tone  of,  176. 
intensity  and  pitch  of,  171. 
musical,  consonant,  170. 
redux,  173. 
resonant,   ringing,  or  metallic,   175, 

176. 

sonorous,  cause  of,  170. 
study  of,  144. 
subcrepitant,  168,  172,  173. 
tracheal,  172. 
transmission  of,  174. 
vesicular,  169. 
viscid  mucous,  elicited  by  whisper, 

190. 

"Rebound"  or  "recoil,"  241. 
Rectus  muscle,  contraction  of,  394. 
Regional  dulness,  diagnostic  value  of, 

115. 

Regurgitation,  aortic,  301,  302. 
mitral,  301,  302. 
pulmonary,  359. 
tricuspid,  302. 
Relational  anatomy  of  regions,  axillary, 

22. 

of  clavicular  regions,  19. 
of  infra-axillary  regions,  22. 
of  infraclavicular  regions,  20. 
of  inframammary  regions,  21. 
of  infrascapular  regions,  23. 
of  interscapular  regions,  23. 


Relational  anatomy  of  mammary  re- 
gions, 20. 

of  scapular  regions,  22. 
of  superior  sternal  regions,  21. 
of  supraclavicular  regions,  19. 
of  suprascapular  regions,  22. 
of  suprasternal  regions,  19. 
Relaxation   of  lung,  mediate  and  im- 
mediate, 119. 
Renal  dulness,  absence  of,  411. 

area  of,  411. 

Renal  tumors,  differentiation  of,  411. 
Resistance  on  palpation,  increased  sense 

of,  72. 

on  percussion,  its  relation  to  vibra- 
tion of  underlying  parts,  96. 
Resonance,  amphoric,  94,  125,   126. 

significance  of,  130. 
deep  and  clear,  93. 
exaggerated  or  abnormally  clear,  1 16. 
impaired,  85. 

points  most  liable  to  reveal,  98. 
where  normal,  130. 
in  children,  88. 

loudness  of,  factors  upon  which  de- 
pendent, 91. 
metallic,  94,  125,  126. 
normal  pulmonary,  86,  93. 
normal  vesicular,  86,  87. 
of  left  side  on  percussion,  100. 
skodaic,  117. 
tussive,  194. 

modifications  of,  194. 
tympanitic,  129. 
variations  in,  87. 
vesicular,  129. 

vesiculotympanitic,  92,  116,  117. 
vocal,  188,  190,  191. 
whispered,  190. 
Respiration,  abdominal,  diaphragmatic 

or  inferior  costal,  31. 
amphoric,  164. 

bronchial,  at  base  of  chest,  162. 
distinguished    from  bronchovesic- 

ular,  162. 
tubular,  161. 
bronchovesicular,  159. 
cavernous,  163,  164. 
Cheyne-Stokes,  60. 
cog-wheel,  155,  311. 

with  hypertrophied  heart,  311. 
compensatory,  153. 
divided,  156. 
during  sleep,  34. 
effect  of,  on  apex-beat,  239. 
exaggerated,  153. 
feeble,  151,  154. 
frequency  of,  31. 
harsh  or  rude,  159. 
intensity  of,  151,  153. 
interrupted,  155. 
jerky,  151. 


INDEX 


451 


Respiration,  lagging,  65. 
nasopharyiigeal,  163. 
normal,  145. 
puerile,  150. 

of  children,  153. 
puffy,  151. 

cardiopulmonary  variety  of,  156. 
rapidity  of,  151. 

as  an  objective  symptom,  4. 
rate  of,  31,  59,  60. 

in  health,  33. 
rhythm  of,  151. 

abnormal,  59,  60,  155. 
senile,  151. 

stage  of,  in  which  rales  occur,  175. 
stridulous,  61. 

subconscious  alteration  of,  34. 
superior  thoracic  or  costal,  31. 
vesicular,  148. 

normal  pitch  of,  158. 
vicarious,  153. 

Respiration  type,  costo-abdominal,  31. 
in  women,  31. 
modified  by  age,  31. 

by  heredity,  31. 
pathologic  alterations  in,  51. 
thoracic  or  upper  costal,  51. 
Respiratory    air,    obstruction    of    the 

flow  of,  59. 

Respiratory  capacity,  index  of,  33. 
Respiratory  change  of  sound,  123. 
Respiratory       conditions,      abnormal, 

sounds  of,  168. 

Respiratory  expansion,  36,  56. 
diminution  of,  in  emphysema,  210. 

local,  56. 
normal,  34. 
Respiratory  movements,  51. 

abdominal,    in    nervous    conditions, 

378. 

as  cause  of  venous  undulations,  341. 
frequency  of,  33. 
normal  types  of,  31. 
of  stomach,  382. 
rhythm,    degree,    and  character  of, 

31. 
Respiratory  murmur,  marked  intensity 

of,  151. 

pitch  and  duration  of,  145. 
quality  and  audibility  of,  145. 
rnythm  of,  145. 

Respiratory  passages,  obstruction  of,  61. 
Respiratory  period,  effect  of,  on  heart 

murmurs,  298. 

Respiratory  pressure,  degree  of,  58. 
Respiratory   rhythm,   acceleration  of, 

59. 

cog-wheel,  156. 
irregularity  of,  60. 
normal,  34. 

relation  of  friction  sounds  to,  181. 
Respiratory  sounds,  abnormal,  152. 


Respiratory  tract,  amount  of  air  with- 
in, 88. 

Retraction,  systolic,  241. 
Retrosternal  dulness,  129. 
Rheumatism,  284. 

inflammatory,  348,  357. 

preceding  mitral  stenosis,  353,  354. 

significance  of  history  of,  349. 
Rhonchi,  168,  169.    ' 

sonorous  and  sibilant,  170. 
Rhythm,  abnormalities  of,  234. 

canter  or  gallop,  278. 

cardiac,  alteration  of,  277. 

recession  in,  241. 
Rib,  seventh,  location  of,  15. 
Ribs,  as  landmarks,  14. 

methods  of  counting,  14. 
Rigidity,  abdominal,  371,  372. 
Rod-pleximeter  percussion,    126. 
Rontgen  examination  of  heart,  426. 

of  intestines,  427. 

of  kidneys,  428. 

of  liver,  428. 

of  pleura,  424. 

of  spleen,  428. 
Rontgen   negatives,   interpretation  of, 

417,  421. 

Rontgen  ray  as  aid  to  diagnosis,  417. 
Rontgenogram,  331,  417,  418,  429. 

of  cardiac  dilation,  426. 

of  cardiac  hypertrophy,  426. 

of  heart,  426. 

of  hemothorax,  425. 

of  hydropneumothorax,  425. 

of  pleural  effusion,  424. 

of  pneumothorax,  424. 

of  thickened  pleura,  424. 

time  of  exposure  for,  419. 
Rontgenograph,  shadows  in,  420. 
Rontgenography,  337,  418. 

in  pulmonary  tuberculosis,  421. 
Rontgenoscopy,  417. 

dangers  of,  418. 

Sansom's  binaural  stethoscope,  137. 

pleximetric  percussion,  252. 
Sarcoma,  of  kidney,  409,  410. 

retroperitoneal,  376,  377. 
Scapula,  location  of,  16. 
Scapular  lines,  18. 

Scapular  regions,  percussion  of,  101. 
Scars,  old,  shadow  of,  421. 
Sciences,     fundamental,    upon    which 

physical  diagnosis  depends,  6. 
Scoliosis,  47. 

Screen  examinations,  418. 
Semeiology,  general,  6. 
Septic   conditions,    as    cause   of  weak 

heart  sounds,  270. 
Septum,  auriculo ventricular,  217. 

interventricular,  217. 
Serratus  magnus,  digitations  of,  15. 


452 


Sex,  influence  of,  in  disease,  205. 
on  percussion  sound,   102,   103. 
on  respiration,  151. 
Sexual  sterility  due  to  Rontgenoscopy, 

418. 

Shadows  in  Rontgenography,  420. 
Shock,  precordial,  in  health,  237. 
Sibson's  furrow,  20. 
Sighing,  causes  of,  60. 
Sigraoid  flexure,  carcinoma  of,  377. 
Sigmoid  loop,  distention  of,  373. 
Sigmoid  region,  enlargements  in,  377. 
"Skeletal  stigmas,"  413. 
"Skin-sense  of  vibrations,"  85. 
Sleep,  costal  breathing  in,  31. 
Sobbing  or  whining  as  cause  of  jerky 

respiration,  151. 
Sounds,   adventitious,    144,    168,    180, 

259,  282. 
differentiation  of,  177. 

associated  attributes  of,  97. 

"bandbox,"  93,  389. 

bronchotracheal,  149. 

bubbling,  387. 

cardiopulmonary,  282,  307. 

cardiorespiratory,  307. 

clear,  of  air-containing  tissue,  86. 

clinking,  387. 

cooing,  390. 

cracked-pot,  127,  128,  130. 

crumpling,  187,  400. 

dead  or  dull,  of  airless  tissue,  86. 

diastolic,  260. 

endocardial,  282. 

exocardial,  282,  308. 

fine  crackling,  187. 

fizzing,  387. 

gurgling,  387. 

humming,  144. 

inspiratory  and  expiratory,  145. 
character  or  quality  of,  152. 
loudness  or  intensity  of,  152. 
pause  between,  152. 
pitch  of,  152. 
relative  lengths  of,  152. 

jugular,  346,  347. 

metallic  tinkling,  168. 

"muffled"  tympanitic,  88. 

non-tympanitic  or  resonant,  86. 

open  tympanitic,  pitch  of,  93. 

percussion,  86. 

pericardial,  282. 

pharyngeal,  146. 

pitch  of,  92,  93,  95. 

pleural  adventitious,  180. 

pleuropericardial,  282. 

resonant,  86. 


rubbing,  400. 
rumbling,  187. 
rustling,  183. 
stethoscopic, 
143. 


discrimination       of, 


Sounds,  succussion  or  splashing,    132, 
168,  185,  311,  387. 

over  cecum,  390. 
systolic,  260. 
tympanitic,  86,  88,  93. 

changes  in  the  pitch  of,  121. 

dull  or  "boardy,"  121. 

open  and  closed,  89,  121. 

pitch  of,  92. 

size  of  communicating  opening  of, 

V/o. 

variations  of,  118. 
with  lowest  pitch,  93. 

vascular,  380. 

vesicular,  intensity  of,  148. 

volume  of,  its  relation  to  pitch,  94. 
Sound-waves,  transmission  of,  425. 
Sphygmograms,  diagrammatic  and  ac- 
tual, 334. 

significance  of  various  lines  of,  332. 
Sphygmograph,  316,  330. 
Sphygmomanometer,  316,  325. 
Spinal  curvature,  47. 
Spine,  distinct  appearance  of,  16. 

dorsal,  exaggerated  curve  of,  210. 
Spirometer,  Hutchinson's,  40. 
Spirometry,  33,  40,  41,  57,  58. 
Splanchnoptosis,  413. 
Spleen,  anatomy  of,  401. 

displaced  or  floating,  377. 

embolus  p.nd  infarct  of,  407. 

enlargement  of,  377,  402,  404,  406, 
412.      (See  also  Table    on    the 
Diagnosis    of    Diseases    of    the 
Liver,  bet.  pp.  396-97.) 
differential  diagnosis  of,  404. 

pathologic,  inspection  of,  402. 
palpation  of,  402. 

relations    of,    to    other    structures, 
402. 

Rontgen  examination  of,  428. 

tumor  of,  in  typhoid,  403. 

wandering  or  floating,  404,  406,  412. 
Spleen-kidney  angle,  411. 
Spleen-lung  angle,  402. 
Splenic  dulness,  absence  of,  406. 

area  of,  405,  407. 

Splenic  tumors,  differentiation  of,  411. 
Spondylitis  deformans,  48. 
Stenosis,  aortic,  233,  274,  301,  302. 

as   cause   of   endocardial   murmurs, 
285. 

mitral,  274,  302. 

murmurs  of,  283. 

of  commencement  of  the  aorta,  241. 

physiologic,  360. 
Sternal  lines,  18. 
Sternum,  location  of,  14. 

percussion  of,  88,  98,  129. 

wooden  tone  of,  247. 
Stethography,  41. 
Stethoscope,  adjustment  of,  136,  144. 


IXDEX 


453 


Stethoscope,  binaural,  135,  137. 

advantages  and  disadvantages  of, 

139. 
general  use  of,  136. 

chest  piece  of,  138. 

choice  of,  141,  259. 

differential,  140. 

double,  136. 

Hawksley's,  135. 

invention  of,  132. 

jointed,  objections  to,  137. 

monaural,  135. 

noises  produced  by,  143. 

of  Bowles,  135,  138,  139. 

of  Cammann,  82,  136. 

of  Laennec,  135. 

of  Valentine,  138. 

single,  disadvantages  of,  135. 

use  of,  142   143. 
in  auscultation,  133. 
in  percussion,  82. 

Stiller's  intercostal  phonation  phenom- 
enon, 56. 

"Stitch"  in  the  side,  60,  178,  201. 
Stokes- Adams  syndrome,  321. 
Stomach,  air-inflated,  metallic  tinkling 
in,  185. 

anatomy  of,  topographic,  381. 

atony  of,  387. 

auscultation  of,  387. 

carcinoma  of,  384. 

cardiac  and  pyloric  orifices  of,  381. 

dilation  of,  377,  382,  383. 

diminished  percussion-area  of,  387. 

diminished  size  of,  387. 

displacement  of,  382,  383,  386. 

distention  of,  269,  375. 
artificial,  385,  387. 
by  gas,  372,  427. 

enlarged,  masking  pneumonia,  205. 

greater  and  lesser  curvatures  of,  381. 

hollow  tone  of,  94. 

normal  position  of,  384,  385. 

opacity  of,  for  examination,  427. 

palpable  portion  of,  382. 

pathologic  conditions  of,  382. 

percussion  of,  94,  384. 

testing  of,  by  means  of  emulsion  of 
bismuth,  427. 

tumors  of,  383,  384,  386. 
Stomach  tube,  use  of,  385. 
Striae  over  abdomen,  369. 
Stridor,  61. 

Structures,  air-containing,  85,  97. 
Subphrenic   abscess,   differential  diag- 
nosis of,  425. 
Subphrenic  friction,  311. 
Succussion  sound,  387. 

in  hydropneumothorax,  185. 

in  pyopneumothorax,  185. 

significance  of  disappearance  of,  186. 
Suction  sound,  post-tussive,  186. 


Supraclavicular  spaces,  percussion  in, 

97. 

Suprarenals.  cancer  of,  376. 
Suprascapular     spaces,  percussion  of, 

101. 

Suprasternal  notch,  14,  18. 
Symptoms  of  disease,  objective,  4. 

subjective  and  objective,  5. 
Syphilis  of  liver,  393,  395. 
Syphilism,  284. 

Systolic  murmur,  subclavian,  339. 
Systolic  sound,  change  in  quality  of, 
269. 

double  rhythm  of,  268. 

duration  and  pitch  of,  261. 

intensity  and  quality  of,  261. 

reduplication  of,  281. 

single,  338. 

valvular  element  of,  268. 

ventricular,  263. 

Tachycardia,  234,  239. 

in  neurotic  females,  307. 

paroxysmal,  320. 
Tap,  dry,  of  the  pleura,  195. 
Temperament,     effect     of,     on    valve 
sounds,  267. 

phlegmatic  and  neurotic,  269. 
Temporal  artery,  pulsation  in,  314. 
Tenderness,  epigastric,  383. 
Test,  coin-clinking,  126. 
Thigh  sound,  85,  89. 
Thoracentesis,  195. 
Thoracometry,  35,  37,  42,  56. 
Thorax.     See  also  Chest. 

anterior  surface  of,  resonance  of,  105. 

deformity  of,  230. 

displacing  apex-beat,  229. 

osseous,  resilience  of,  88. 

posterior  regions  of,  percussion  of, 

101. 
Thrill,  189,  236. 

cardiac,  241. 

diastolic,  of  mitral  stenosis,  242. 

due  to  valvular  lesions,  243. 

hydatid,  396. 

location,    rhythm,    and    extent    of, 
242. 

presystolic,  354. 

purring,  354. 

systolic,  243. 

Thrombosis,  venous,  209,  346. 
Tissue,  airless,  85. 

differentiated  from  air-containing, 
91. 

solid,  85. 

vesicular,    diminished   elasticity   of, 

155. 
Tone,  elements  of,  relations  of,  96. 

musical,  86,  166,  170. 
Tonometer,  316. 

of  Gaertner,  326. 


454 


INDEX 


Topographic   percussion,   accuracy  of 

104. 

conditions  necessary  for,  10.3. 
method  of,  103. 
Trachea,  bifurcation  of,  27. 
Tracheal  resonance  of  Williams,  124. 
Tracheal  tug,  315. 
Tracheal  whisper,  normal,  189. 
Tracheobronchial  column  of  air,  146. 
Tracheophony,  normal,  188. 
Transudate,  dropsical,  372. 
Traube's  semilunar    space,     101,    129, 

382,  384. 
diminution    of   tympanitic   area   in, 

114. 
Treatment    dependent   upon    physical 

diagnosis,  8. 
Tremor,  323. 
Trichterbrust,  46. 
Tricuspid  area,  diminished  first  sound 

in,  272. 

Tricuspid  insufficiency,  relative,  351. 
Tricuspid  regurgitation,  243,  307,  343. 

phenomena  of,  353. 
Tricuspid    stenosis,    differentiation   of, 

356. 

Tricuspid  valve,  219. 
Tubal  swellings,  376. 
Tubercles,  old  calcified,  shadow  of,  421. 
Tuberculous  consolidation,  breathing  of, 

161. 

Tuberculous  infiltration,  incipient,  159. 
Tuberculosis,    acute    miliary,    rustling 

sound  in,  183. 

chronic,  heart  sound  in,  269. 
crepitant  rales  in,  178. 
diagnosis  of,  191. 
incipient,  diagnostic  sign  of,  179. 
of  bowel,  chronic,  389. 
pulmonary,  changes  in  shape  of  chest 

in,  42,  43. 

early,  of  one  apex,  109. 
physical  evidences  of,  147. 
value  of  palpation  in,  64. 
indicated  by  deficiency  of  lung  ca- 
pacity, 57. 

marked  vocal  fremitus  in,  68. 
of  apices,  110,  339. 
stethoscopic  examination  in,  135. 
Tuberculous  cavity,  diagnosis  of,  55. 
"Tubular"  note,  94. 
Tumors,  abdominal,  372,  375. 
displacing  apex-beat,  229. 
pressing  on  liver,  400. 
symptoms  of,  374. 
aneurismal,  193. 
as  cause  of  elastic  equilibrium  of  lung 

119. 

evanescent,  in  emphysema,  210. 
intestinal,  390. 
malignant,  193. 
mediastinal,  112,  339. 


Tumors,  muscular,  372. 

of  chest  wall,  51. 

of  gall-bladder,  397. 

of  kidney,  377. 

of  liver  and  gall-bladder,  383. 

of  lung,  111. 

ovarian,  376,  377. 

overlying  aorta,  227. 

renal,  410. 

replaceable,  413. 

splenic,  403,  411,  413. 
differentiation  of,  411. 

tympanicity  of,  379. 
Tympanites,  367,  373. 
Tympanitic  sound,  elicited  in  ascites, 
379. 

exaggerated,  378. 
Tympany,  apical,  119. 

gastric,  382,  384,  398,  406. 
diminution  of,  130. 
distinguished    from    colonic,    384, 
385. 

general,  385. 

intestinal,  398. 

variations  in,  118. 
Typhoid  fever,  splenic  tumor  in,  403. 

Ulcer,  gastric,  383. 

Umbilical  region,  enlargement  of,  377. 

waves  around,  significance  of,  369. 
Umbilicus,  as  a  landmark,  366. 

leveling,  or  protrusion  of,  369. 

thickening,   fixation,  and  retraction 

of,  372. 

Undulations  of  veins,  340. 
Uterine  souffle,  339. 
Uterus,  fibroid  enlargement  of,  377. 

pregnant,  systolic  murmur  in,  339. 

Valve  areas,  264. 

aortic,  265. 

mitral,  264. 

of  maximum  intensity,  264. 

pulmonic,  266. 

topographic-anatomic,  301. 

tricuspid,  266. 
Valve  leaflets,  calcareous  excrescences 

upon,  297. 
Valve  shocks,  244. 
Valve  sounds,  individual,  variations  in, 

267. 
Valves,  insufficiency  of,  284,  285. 

jugular  and  tricuspid,  incompetence 

of,  345. 

Valves    of   heart,    auriculoventricular, 
219. 

lesions  of,  270. 

positions  of,  219. 
Valvular  lesions,  combinations  of,  301.. 

degree  and  nature  of,  297. 
Valvular  murmurs,  aortic,  285. 

mitral,  285. 


IXDEX 


455 


Valvular  murmurs,  pulmonary,  285. 

tricuspid,  285. 
Vegetations  on  valves,  289. 
Veiled  puff,  186. 

Veins,   abdominal,   enlarged  and   tor- 
tuous, 368. 
collapse  of,  343. 
engorgement  of,  340. 
fulness  of,  340. 
"milking"  of,  343,  345. 
pulsation  of,  340. 
superficial,  enlargement  of,  340. 
Vena  cava,   superior,  compression  of, 

341. 

position  of,  218. 
Venous  distention,  general,  340. 

local,  340. 
Venous  hum,  346. 
intensity  of,  347. 
intermittent,  347. 
pathologic,  347. 
physiologic,  346. 
Venous  liver  pulse,  345. 
Venous  pulsations,  341. 

due  to  cardiac  conditions,  342. 
due  to  respiratory  movements,  341. 
hepatic,  393. 
propagation  of,  345. 
Venous  pulse,  diagnosis  of,  344,  346. 
in  health,  342. 
negative,  342,  343. 
normal,  343. 
positive  centrifugal,  344. 
presystolic,  342,  343. 
progressive,  346. 
systolic  or  positive,  343. 
Venous  thrombosis,  209. 
Venous  undulations,  341. 
Ventricle,  left,  dilation  of,  229,  358. 
enlargement  of,  253. 
hypertrophy  of,  229,  271. 
hypertrophy  and  dilation  of,  229, 

230,  358. 

regurgitation  of  blood  into,  358. 
right,  competency  of,  275. 
dilation  of,  227,  305. 
hypertrophy  of,  227,  275,  315,  351. 
strain  upon,  227. 
Ventricles,  enlargement  of,  426. 

excessive  pressure  within,  281. 
Vertebra  prominens,  15,  17. 
Vertebral   spines,   tips  of,   as   guides, 

15. 

Vesicles,  consolidation  of,  191. 
Vesicular  breathing,  148. 

diminished  intensity  of,  in  the  aged, 

150. 

influence  of  age  upon,  150. 
normal  variations  in,  150. 
origin  of,  149. 
pitch  of,  148. 
quality  of,  148. 


Vesicular  breathing,  relative  duration  of 
inspiration  and  expiration  in,  148. 

rhythm  of,  149. 
Vesiculotympany,  117,  212. 

as  sign  of  disease,  130. 
Vibrations,  thoracic,  65. 
Viscera,    congenital    transposition    of, 

230. 
Vital  capacity,  40. 

abnormal,  57. 

criterion  of,  57. 
Vocal  fremitus,  absence  of,  69. 

dependent  upon  distance  from  larynx 

of  part  examined,  66. 
upon  pitch  of  voice,  66. 
upon  size  or  diameter  of  the  bron- 
chus, 66. 
upon  thickness  of  chest  wall,  66. 

diminution  of,  67,  68. 

in  hypostasis,  207. 

increase  of,  66,  67. 

normal  variations  in,  66. 

pathologic  changes  in,  67. 
Vocal  resonance,  artificial,  194. 

clinical  significance  of,  188. 

diminished  or  absent,  193. 

in  disease,  190. 

normal,  189. 

study  of,  144. 

tested  in  the  dumb,  194. 
Voice,  amphoric,  190,  193. 

auscultation  of,  188. 

bleating  quality  of,  190. 

pitch  of,  66. 

spoken,  188. 

whispered,  188,  191. 
Voice  sounds,  normal,  188. 

without  fremitus,  189. 
Volvulus,  373. 
Vomicse.    See  Pulmonary  Cavities. 

Wasting  diseases,  chronic,  272. 

functional  murmur  in,  305. 
Water-hammer  pulse,  358. 
Water-whistling,  186. 
Wave,  dicrotic  or  recoil,  332. 

hyperdicrotic,  333. 

outflow-remainder,  332. 

predicrotic  or  tidal,  332. 
Weil's  disease.  (See  Table  on  the  Diag- 
nosis of  Diseases  of  the  Liver, 
bet.  pp.  396-97.) 
Whisper,  exaggerated,  191. 
Whisper  bronchophony,  189. 
Whispered  resonance,  normal,  189. 
Whispered  voice  in  disease,  190. 
Williams's  tracheal  tone,  124. 
Winter  cough,  158. 

of  old  people,  277. 

Wintrich's  change  of  sound,  121,  122, 
124,  126. 

interrupted,  123. 


456 


INDKX 


Wrist  percussion,  ease  and  elasticity  of. 

80. 
how  to  practise,  80. 

X-rays.  See  also  Riintgen  Ray. 
Xiphocostal  angle,  squirting  sound  at, 

387. 
Xiphoid  and  navel,  carcinoma  between, 

384. 

Xiphoid  junction,  murmur  above,  358. 
percussion  dulness  around,  354. 


Yellow  atrophy  of  t  he  liver.  (See  Table 
on  the  Diagnosis  of  Diseases  of 
the  Liver,  bet.  pp.  396-97.) 


Ziemssen's  method  of  distending  stom- 
ach, 385. 
Zones,  anatomic,  of  abdomen,  363. 

epigastric,  363. 

hypogastric,  363. 

mesogastric,  363. 


(1) 


THE   END 


THE  PRINCIPLES  AND 
PRACTICE    OF    MEDICINE 

By  WILLIAM   OSLER,   M.D. 

Fellow  of  the  Royal  Society;   Fellow  of  the  Royal -College  of  Physicians,  London; 
Regius  Professor  of  Medicine,  Oxford  University  ;  Honorary  Professor  of  Medi- 
cine, Johns  Hopkins  University,  Baltimore;  formerly  Professor  of  the 
Institutes  of  Medicine,  McGill   University,  Montreal;    and 
Professor  of  Clinical  Medicine  in  the  University  of 
Pennsylvania,  Philadelphia 

THE    WORK    HAS    BEEN    REVISED,    REWRITTEN,    RESET,   ENLARGED, 
AND  BROUGHT  UP  TO  DATE  IN  ALL  DEPARTMENTS 

Sixth  Edition 
8vo.     1182  pages.     Cloth,  $5.50  net 

"  Practices  soon  get  old  on  the  shelf  and  need  frequent  reviewing. 
It  is  well  to  look  and  see  if  one  really  has  an  up-to-date  practice ;  if 
not,  get  this  new  Osier.  No  single  work  on  the  subject  can  speak  with 
an  equal  voice  of  authority.  It  is  probably  the  world's  leading  work 
on  practice." — Texas  State  Journal  of  Medicine. 

"  This  work  has,  since  its  first  edition,  been  one  of  the  standard 
one-volume  '  practices,'  and  is  not  likely  to  soon  lose  its  status  as  such. 
The  last  edition  contains  the  results  of  the'  latest  research  upon  the 
subjects  with  which  it  deals,  and  the  work  is  one  to  be  highly  recom- 
mended."— New  York  Medical  Review  of  Reviews. 

"  Osier's  classical  work  has  been  copyrighted  eight  times  in  the 
past  thirteen  years  ;  has  gained  a  greater  circulation  than  any  practice 
of  medicines  ever  secured  in  America;  has  now  reached  its  sixth  edi- 
tion and  undoubtedly  represents  the  high- water  mark  of  medical  lit- 
erature in  the  English-speaking  world.  To  know  Osier's  '  Practice ' 
thoroughly  is  to  be  acquainted  with  the  best  exemplification  of  modern 
medicine.  It  should  be  found  in  the  hands  of  all  our  readers." 

— Illinois  Medical  Journal. 

"  This  is  no  mere  revision.  Upon  examination  the  work  is  found 
to  be  largely  rewritten  from  the  standpoint  of  the  latest  experiences  in 
the  entire  range  of  medicine.  The  preeminent  place  it  has  occupied 
as  a  text  book  and  work  of  reference  is  more  than  renewed  by  this 
edition." — The  Chicago  Medical  Recorder. 

D.     APPLETON     AND     COMPANY,     NEW     YORK 


OPERATIVE   SURGERY. 


BY  JOSEPH  D.   BRYANT,  M.  D., 

Professor  of  the  Principles  and  Practice  of  Surgery,  Operative   and   Clinical  Surgery, 

University   and   Bellevue   Medical   College  ;    Visiting  Surgeon  to  Bellevue 

and  St.  Vincent's  Hospitals  ;  Consulting  Surgeon  to  the  Hospital 

for  Ruptured  and  Crippled,   Woman's   Hospital,    and 

Manhattan  State  Hospital  for  the  Insane,  etc. 

FOURTH  REVISED  EDITION. 

In  Two  8vo  Volumes.     1,302  pages.     1.700   Illustrations,    100  of 
which  are  in  Color.     Sold  by  Subscription.     Cloth,  $10.00. 


"The  publication  of  this  volume,  somewhat  delayed  apparently,  completes  one  of 
the  best  works  on  operative  surgery  in  existence,  and  we  therefore  greet  it  with  pleas- 
ure. The  title  recites  the  contents  of  the  volume,  in  which  we  find  much  of  what 
is  most  important  in  surgery.  The  pictures  are  graphic  and  handsomely  executed,  and 
the  plan  of  giving  illustrations  of  the  instruments  required  in  particular  operations  is 
maintained.  The  author's  literary  style  is  so  good  that  much  is  added  thereby  to  the 
pleasure  of  reading  the  book." — Medical  Record. 

"This  book  is  to  be  commended  without  reservation  as  an  admirable  guide  to 
both  the  skilled  surgeon  and  the  practitioner  who  is  occasionally  called  on  to  do  sur- 
gical work." — Therapeutic  Gazette. 

"The  two  volumes  of  the  work  fulfil  every  practical  need  of  the  practising  surgeon, 
and  are  perfect  typographically." — Denver  Medical  Times. 

"It  is  seldom  that  one  meets  with  such  an  eminently  satisfactory  work  as  the 
second  volume  of  Bryant's  'Operative  Surgery.'  One  feature  of  especial  importance 
in  the  work  is  the  illustrations.  No  present-day  work  on  operative  surgery  can  be 
satisfactory  without  the  aid  of  good  illustrations,  and  in  this  respect  Bryant's  work  is 
very  complete." — Philadelphia  Medical  Journal. 

"  The  high  standard  of  excellence  established  in  the  first  volume  of  Dr.  Bryant's 
work  is  fully  maintained  in  this,  the  second  volume,  so  that  this  text-book  on  opera- 
tive surgery  presents  a  complete,  exhaustive,  and  valuable  treatise  of  this  important 
branch  of  medicine.  A  reading  of  both  volumes  will  convince  any  one  that  Dr.  Bryant 
has  something  to  say,  and  that,  better  than  this,  he  well  knows  how  to  say  it.  The 
book  is  eminently  practical  and  concise,  and  is  a  real  addition  to  the  literature  of  this 
important  and  much-treated  subject." — journal  of  Medicine  and  Science. 

"The  surgeon  who  remains  without  these  two  volumes  of  Bryant's  'Operative 
Surgery' — especially  a  beginner  in  surgery— deprives  himself  of  one  of  the  valuable 
helps  that  he  could  desire." — Virginia  Medical  Semi-Monthly. 

D.    APPL  ETON    AND     COMPANY,    NEW    YORK. 


THE  DISEASES  OF  INFANCY 
AND  CHILDHOOD. 

By  L  EMMET  HOLT,  M.D.,  Sc.D.,  LLD., 

Professor  of  Diseases  of  Children  in  the  College  of  Physicians  and  Surgeons  (Columbia 
University),  New  York;  Attending  Physician  to  the  Babies' and  Foundling  Hospitals, 
New  York;  Consulting   Physician  to  the  New  York  Infant  Asylum,  Lying- 
in  Hospital,  Orthopedic,  and  Hospital  for  the  Ruptured  and  Crippled. 

THIRD   EDITION,    REVISED    AND    ENLARGED,    WITH    TWO 

HUNDRED    AND   FORTY-FIVE   ILLUSTRATIONS, 

INCLUDING  NINE  COLORED   PLATES. 

Cloth,  $6.00 ;  half  leather,  $6.50. 

Sold  only  by  Subscription. 

"Throughout  the  work  the  evidence  of  careful  revision  is  everywhere  apparent, 
and  the  volume  represents  essentially  the  best  exposition  of  the  latter-day  pediatnc 
teaching." — Cleveland  Medical  Journal. 

"  This  second  edition  is  even  better  than  the  first,  and  more  than  retains  the  high 
position  taken  by  its  predecessor.  No  one  interested  in  the  diseases  of  childhood  can 
afford  to  be  without  it." — Boston  Medical  and  Surgical  Journal. 

"  No  radical  departure  from  the  previous  edition  has  been  instituted  in  this  the 
second  edition.  The  material  has,  however,  undergone  a  thorough  revision,  with  the 
addition  of  new  and  thoroughly  tried  methods  of  diagnosis  and  treatment  which  have 
been  accepted  since  the  appearance  of  the  previous  edition.  The  most  noteworthy 
change  has  been  in  the  chapter  on  Milk  and  Infant  feeding.  This  section  has  been 
completely  rewritten,  with  the  addition  of  much  new  and  valuable  material  in  accord 
with  the  great  advance  made  in  this  important  branch  of  pediatrics.  Old  illustrations 
have  been  replaced  by  newer  and  better  ones.  New  charts  and  diagrams,  with  twenty- 
one  additional  illustrations,  enhance  the  value  of  an  already  accepted  standard  work." 
—  Yale  Medical  Journal. 

'  Holt  is  recognized  as  one  of  the  foremost  authorities  on  pediatrics  of  America, 
and  therefore  of  the  world.  He  has  made  a  very  extensive  first-hand  study  of  the  care 
of  children  and  their  diseases,  and  so  writes  from  a  mind  replete  with  the  clinical 
pictures  of  suffering  childhood.  The  work  is  complete  from  every  practical  standpoint, 
and  the  text  embraces  1161  octavo  pages.  The  student  or  practitioner  who  has  Holt 
at  hand  need  hardly  ever  be  at  a  loss  for  a  reliable  line  of  treatment  in  his  pediatric 
practise." — Denver  Medical  Times. 

"The  changes  within  the  past  five  years  have  not  been  very  extensive,  yet  the 
many  new  facts  that  have  come  out  in  the  rapidly  advancing  science  of  pediatrics  have 
here  all  received  their  share  of  careful  and  judicial  treatment. 

"The  extremely  practical  question  of  infant  feeding,  as  is  well  known,  has  been  a 
subject  of  special  study  by  the  author,  and  one  in  which  medical  advances  have  been 
made  very  largely  identified  with  his  name.  It  is  a  pleasure  to  find  the  subject  han- 
dled in  a  text-book  in  a  comprehensive  and  yet  common-sense  manner." — New  York 
Medical  News. 

D.    APPLETON     AND     COMPANY,    NEW    YORK. 


OBSTETRICS. 

A    TEXT-BOOK  FOR    THE   USE  OF  STUDENTS  AND 
PRACTITIONERS. 

BY  J.  WHITRIDGE   WILLIAMS, 

Professor  of  Obstetrics,  Johns  Hopkins  University;  Obstetrician-in-Chief  to  the  Johns 
Hopkins  Hospital;  Gynecologist  to  the  Union  Protestant  Infirmary,  Baltimore,  Md. 

SAY   HUNDRED  AND    THIRTY  ILLUSTRATIONS  IN   THE    TEXT 
AND  EIGHT  COLORED   PLATES. 

Cloth,  $6.00;    Half  Leather,  $6.50. 

SOLD   ONLY    BY   SUBSCRIPTION. 


"The  studies  of  the  anatomy  of  the  uterus  and  its  adnexa  are  unique,  and  afford 
the  student  opportunity  for  attractive  occupation  in  the  acquirement  of  completer 
knowledge.  The  development  of  the  ovum  and  placenta  has  never  been  set  forth  as 
well  in  a  work  on  obstetrics,  according  to  our  view,  as  by  Williams.  The  illustrations 
showing  the  structure  of  the  placenta  are  admirable. 

"In  the  section  on  obstetric  surgery,  beginning  with  induction  of  abortion  and  ac- 
couchement force,  including  forceps  and  version,  Cesarean  section  and  symphysiotomy, 
destructive  operations,  and  ending  with  operative  procedures  which  do  not  aim  at  a 
delivery,  is  found  quite  the  most  ample  handling  of  operative  obstetrics  that  has  yet 
been  published  in  such  a  treatise.  Here,  again,  illustrations  supplement  the  text  in  an 
instructive  fashion. 

"  Williams's  dealing  with  contracted  and  otherwise  deformed  pelves,  and  the  man- 
agement of  labor  in  such  conditions,  is  most  satisfactory.  Injuries  of  the  birth  canal, 
infection,  hemorrhage,  and  the  puerperium  are  all  prepared  by  one  who  understands  the 
greatest  need  of  the  student,  and  he  tells  him  in  the  fewest  and  plainest  words  possible 
what  he  must  know  to  obtain  success  in  the  practice  of  obstetrics.  It  is  a  book  made 
by  a  clinician,  which  gives  the  most  advanced  exposition  of  the  art  and  is  a  distinct 
addition  to  obstetric  literature. 

"Much  original  work  has  been  done  in  the  way  of  illustration,  as  well  as  in  the 
preparation  of  the  material  of  many  chapters,  and  the  whole  subject-matter  is  presented 
in  an  original  manner.  The  book  is  a  credit  to  both  author  and  publisher." — Buffalo 
Medical  Journal. 

"  At  a  certain  examination  the  question  was  asked:  '  Describe  the  management  of  a 
face  presentation  in  the  M.  D.  P.  position.'  The  examined  men  were  like  '  sheep  before 
the  shearers' — i.  e.,  dumb.  An  investigation  showed  that  the  popular  text-book  made 
scant  reference  to  the  so-called  '  undeliverable  '  position. 

"  Perhaps  a  knowledge  of  this  fact  led  the  reviewer  of  Dr.  Whitridge  Williams's 
work  to  consider,  first,  the  description  of  the  presentation  in  general,  and,  second,  those 
of  the  face  in  particular.  The  admirable  methods  employed  in  explanation  and  the 
ample  demonstrating  drawings  illustrating  these  fundamentals  of  obstetric  knowledge 
show  that  the  author  is  that  rare  combination,  a  teacher  and  a  student  of  students  and 
their  requirements. 

"  Everything  is  detailed  to  the  required  minuteness,  and  beyond  that  nothing.  The 
cuts  and  engravings  are  many,  novel  and  good.  They  fill  a  definite  purpose,  and  that 
purpose  is  not  'padding.'  As  one  reads  page  after  page  the  old-fashioned  words, 
'  Pleasure  and  profit,'  recur  to  the  mind. 

"  It  has  all  the  earmarks  of  success;  it  is  crowded  with  hints  of  practical  value,  and 
it  shows  what  the  trained  hand  and  brain  adopt  as  the  best  methods  in  overcoming  the 
obstacles  of  parturition.  Surely,  if  conscientious  work  and  real  merit  count,  we  may 
expect  to  find  this  volume  upon  the  lists  of  the  colleges  and  treasured  in  private  libra- 
ries."— New  York  State  Journal  of  Medicine. 

D.  APPLETON  AND  COMPANY,  NEW  YORK. 


Date  Due 


PRINTED   IN    U.S.A. 


CAT.   NO.  24   161  (**f 


Anders . 

Physical  diagnosis 


WB200 
A5Mp 
1907 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


